Healthcare Provider Details

I. General information

NPI: 1811174279
Provider Name (Legal Business Name): GREENWOOD REGIONAL RHEUMATOLOGY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BYPASS 225 S
GREENWOOD SC
29646-8025
US

IV. Provider business mailing address

PO BOX 427
GREENWOOD SC
29648-0427
US

V. Phone/Fax

Practice location:
  • Phone: 864-953-8002
  • Fax: 864-953-9690
Mailing address:
  • Phone: 864-953-8002
  • Fax: 864-953-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number15159
License Number StateSC

VIII. Authorized Official

Name: DR. JOHN TRIMMER HICKS
Title or Position: PHYSICIAN/PRACTICE OWNER
Credential: M.D.
Phone: 864-953-8002