Provider Demographics
NPI:1962644773
Name:PELHAM MEDICAL CENTER
Entity Type:Organization
Organization Name:PELHAM MEDICAL CENTER
Other - Org Name:PELHAM MEDICAL CENTER PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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 198886
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8886
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:864-560-4023
Practice Address - Street 1:250 WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-9013
Practice Address - Country:US
Practice Address - Phone:864-530-2108
Practice Address - Fax:864-530-2121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-26
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5160Medicaid
SCDR2239Medicare PIN
SC9225Medicare PIN