Provider Demographics
NPI:1912163874
Name:SPARTANBURG REGIONAL MEDICAL CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MEDICAL CTR
Other - Org Name:REGIONAL PSYCHIATRY AT VILLAGE OF PELHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-4475
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:864-560-7517
Mailing Address - Fax:
Practice Address - Street 1:2755 S HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-560-7517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCN1627OtherRR MEDICARE
SCGP1118Medicaid
SC7652Medicare PIN