Healthcare Provider Details

I. General information

NPI: 1730137092
Provider Name (Legal Business Name): CHESTERFIELD-MARLBORO, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 CHESTERFIELD HWY
CHERAW SC
29520-7002
US

IV. Provider business mailing address

711 CHESTERFIELD HWY
CHERAW SC
29520-7002
US

V. Phone/Fax

Practice location:
  • Phone: 843-320-3304
  • Fax: 843-320-3480
Mailing address:
  • Phone: 843-320-3304
  • Fax: 843-320-3480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateSC

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 866-398-7108