Healthcare Provider Details

I. General information

NPI: 1376546903
Provider Name (Legal Business Name): CHESTERFIELD CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 CHESTERFIELD HWY
CHERAW SC
29520-7002
US

IV. Provider business mailing address

721 CHESTERFIELD HWY
CHERAW SC
29520-7002
US

V. Phone/Fax

Practice location:
  • Phone: 843-921-1211
  • Fax: 843-921-1213
Mailing address:
  • Phone: 843-921-1211
  • Fax: 843-921-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626