Provider Demographics
NPI:1801206123
Name:SPARTANBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:SPARTANBURG MEDICAL CENTER
Other - Org Name:MEDICAL GROUP OF THE CAROLINAS - INTERNAL MEDICINE - EASTSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEMS CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
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:
Practice Address - Street 1:1650 SKYLYN DR STE 220
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1069
Practice Address - Country:US
Practice Address - Phone:864-560-9056
Practice Address - Fax:864-560-9057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG HEALTH SERVICES DISTRICT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5019OtherMEDICARE PIN
SCGP6478Medicaid