Provider Demographics
NPI:1871694620
Name:ABBEVILLE COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:ABBEVILLE COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-366-3279
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-0887
Mailing Address - Country:US
Mailing Address - Phone:864-366-5011
Mailing Address - Fax:864-366-3317
Practice Address - Street 1:763 HIGHWAY 28 BYP STE 17
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5596
Practice Address - Country:US
Practice Address - Phone:864-366-9151
Practice Address - Fax:864-366-0018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABBEVILLE COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251E00000X
SCHTL-098251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC470744Medicaid
SC=========999OtherBLUE CROSS BLUE SHIELD SC
SC470744Medicaid
SC427076Medicare Oscar/Certification
42-7076Medicare PIN
SC427076Medicare PIN