Healthcare Provider Details

I. General information

NPI: 1275692501
Provider Name (Legal Business Name): MARLBORO CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MARLBORO WAY SUITE 8
BENNETTSVILLE SC
29512-2494
US

IV. Provider business mailing address

1040 MARLBORO WAY SUITE 8
BENNETTSVILLE SC
29512-2494
US

V. Phone/Fax

Practice location:
  • Phone: 843-454-1100
  • Fax: 843-454-0110
Mailing address:
  • Phone: 843-454-1100
  • Fax: 843-454-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 800-709-7345