Provider Demographics
NPI:1770895674
Name:CHESTERFIELD-MARLBORO LP
Entity type:Organization
Organization Name:CHESTERFIELD-MARLBORO LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:888-304-1079
Mailing Address - Fax:615-469-6629
Practice Address - Street 1:1138 CHERAW HWY
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2466
Practice Address - Country:US
Practice Address - Phone:843-454-8400
Practice Address - Fax:843-479-5860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERFIELD-MARLBORO LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-08
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RC0000X, 367500000X
SC207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC203749OtherUNISON
NC5916149Medicaid
SC400541Medicaid
NC8053756Medicaid
SC203749OtherUNISON