Provider Demographics
NPI:1184989840
Name:SENTINEL HEALTH PARTNERS, PA
Entity type:Organization
Organization Name:SENTINEL HEALTH PARTNERS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, I.T.
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-713-8350
Mailing Address - Street 1:PO BOX 1259
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29021-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1344 HAILE ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3076
Practice Address - Country:US
Practice Address - Phone:803-432-1996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENTINEL HEATH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-09
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42D0248605291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
002OtherBCBS OF SC
SCGP1679Medicaid
SC0001OtherPTAN