Healthcare Provider Details

I. General information

NPI: 1043219637
Provider Name (Legal Business Name): MARLBORO CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MARLBORO WAY SUITE 7
BENNETTSVILLE SC
29512-2494
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-3280
US

V. Phone/Fax

Practice location:
  • Phone: 843-479-5858
  • Fax: 843-454-1092
Mailing address:
  • Phone: 866-398-7108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813