Provider Demographics
NPI:1700176054
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:MAGNOLIA PLASTIC SURGERY-ROCKY SLOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:29 ROCKY SLOPE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3909
Practice Address - Country:US
Practice Address - Phone:864-286-9229
Practice Address - Fax:864-286-9228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-07
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1118Medicaid
SCGP1118Medicaid