Provider Demographics
NPI:1740216191
Name:LORIS MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:LORIS MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-756-5300
Mailing Address - Street 1:3439 CASEY ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-2903
Mailing Address - Country:US
Mailing Address - Phone:843-756-5300
Mailing Address - Fax:843-756-6059
Practice Address - Street 1:3439 CASEY ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2903
Practice Address - Country:US
Practice Address - Phone:843-756-1582
Practice Address - Fax:843-756-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4771OtherPALMETTO MEDICARE
SCGP1053Medicaid
SCCA6664OtherRAILROAD MEDICARE
NC5950200Medicaid
NC0291JOtherNORTH CAROLINA BCBS