Basic Information
| Provider Information | |||||||||
| NPI: | 1194016097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENCY HOSPITAL OF GREENVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SAINT FRANCIS DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296013955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT FRANCIS DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296013955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2011 | ||||||||
| LastUpdateDate: | 04/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11345A | 05 | SC | MEDICAID |