Provider Demographics
NPI:1679514418
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:PALMETTO PEDIATRICS NORTH GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MEINKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1330 BOILING SPRINGS ROAD
Practice Address - Street 2:SUITE 1300
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4204
Practice Address - Country:US
Practice Address - Phone:864-560-6345
Practice Address - Fax:864-560-6054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-10
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908005Medicaid
SCGP1118Medicaid
SCGP5634Medicaid
SC=========045OtherBCBS GROUP#
SCGP5634Medicaid