Basic Information
| Provider Information | |||||||||
| NPI: | 1326276551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLYBURN-IPOCK | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4375 BETHUNE HWY | ||||||||
| Address2: | |||||||||
| City: | BETHUNE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290099334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034842602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 555 EAST CHEVES ST | ||||||||
| Address2: | MCLEOD HEALTH HOSPITAL - RADIATION ONCOLOGY | ||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437772000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | TL31724 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.