Provider Demographics
NPI:1396779856
Name:MARION MEDICAL GROUP PA
Entity type:Organization
Organization Name:MARION MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:E
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-431-2405
Mailing Address - Street 1:1115 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-2025
Mailing Address - Country:US
Mailing Address - Phone:843-423-0760
Mailing Address - Fax:843-423-8138
Practice Address - Street 1:1115 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-2025
Practice Address - Country:US
Practice Address - Phone:843-423-0760
Practice Address - Fax:843-423-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC075Medicaid
SC423852Medicare ID - Type Unspecified
SCRHC075Medicaid