Healthcare Provider Details

I. General information

NPI: 1720092570
Provider Name (Legal Business Name): MARION REGIONAL HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 E HIGHWAY 76 SUITE 5A
MULLINS SC
29574-6037
US

IV. Provider business mailing address

PO BOX 1150
MARION SC
29571-1150
US

V. Phone/Fax

Practice location:
  • Phone: 843-431-2710
  • Fax: 843-431-2716
Mailing address:
  • Phone: 843-431-2710
  • Fax: 843-431-2716

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
Identifier288183
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
IdentifierGP4562
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: HAROLD E TUCKER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 843-431-2405