Basic Information
| Provider Information | |||||||||
| NPI: | 1598799017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABBEVILLE COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ABBEVILLE UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 887 | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296200887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643661649 | ||||||||
| FaxNumber: | 8643663317 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 W GREENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296205678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643666060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROCHELLE | ||||||||
| AuthorizedOfficialFirstName: | MARY BETHE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PAYOR CONT & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8643661649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ABBEVILLE COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | GP4449 | 05 | SC | MEDICAID |