Provider Demographics
NPI:1013939529
Name:RICHLAND COMMUNITY HEALTH CARE ASSOCIATION
Entity Type:Organization
Organization Name:RICHLAND COMMUNITY HEALTH CARE ASSOCIATION
Other - Org Name:CAROLINA MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-799-8407
Mailing Address - Street 1:1520 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2623
Mailing Address - Country:US
Mailing Address - Phone:803-799-8407
Mailing Address - Fax:803-252-9070
Practice Address - Street 1:3010 FARROW RD
Practice Address - Street 2:SUITE 230
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7607
Practice Address - Country:US
Practice Address - Phone:803-799-1284
Practice Address - Fax:803-799-8148
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHLAND COMMUNITY HEALTH CARE ASSOCIATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-24
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
SC20390261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC030Medicaid
SCGP4435Medicaid
SCCBP006Medicaid
SCFQC043Medicaid
SCGP4435Medicaid
SC7131Medicare PIN
SC7131Medicare ID - Type UnspecifiedLOCAL