Healthcare Provider Details

I. General information

NPI: 1265901359
Provider Name (Legal Business Name): SPARTANBURG MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 INGLES DR
INMAN SC
29349-8314
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-342-4090
  • Fax: 864-578-7098
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGP8756
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier6084
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICARE PIN

VIII. Authorized Official

Name: BRUCE A DAVIS
Title or Position: CHIEWF FINANCIAL OFFICER
Credential:
Phone: 864-560-6000