Provider Demographics
NPI:1336439314
Name:LCHCS DBA WILSON AND MCCORMACK SURGICAL SERVICES
Entity Type:Organization
Organization Name:LCHCS DBA WILSON AND MCCORMACK SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP AND CFO OF LCHCS
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:864-833-3976
Mailing Address - Street 1:1012 MEDICAL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-4542
Mailing Address - Country:US
Mailing Address - Phone:864-833-3852
Mailing Address - Fax:
Practice Address - Street 1:1012 MEDICAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-4542
Practice Address - Country:US
Practice Address - Phone:864-833-3852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LCHCS DBA WILSON AND MCCORMACK SURGICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33377208600000X
SC33343208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2815Medicare UPIN