Provider Demographics
NPI:1720160450
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Other - Org Name:MYRTLE BEACH PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-482-0064
Mailing Address - Street 1:PO BOX 1844
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-1844
Mailing Address - Country:US
Mailing Address - Phone:864-482-0064
Mailing Address - Fax:864-482-0081
Practice Address - Street 1:4237 RIVER HILLS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6444
Practice Address - Country:US
Practice Address - Phone:843-249-5616
Practice Address - Fax:843-249-1843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes273Y00000XHospital UnitsRehabilitation UnitGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5092260004OtherDMERC PROVIDER #
SC426584Medicare Oscar/Certification