Basic Information
| Provider Information | |||||||||
| NPI: | 1497798599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACK RIVER HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRH - KINGSTREE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291022925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034331216 | ||||||||
| FaxNumber: | 8034336796 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 THURGOOD MARSHALL BLVD. | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433555628 | ||||||||
| FaxNumber: | 8433556072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8034331216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLACK RIVER HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4397 | 01 | SC | MEDICARE PART B | OTHER |