Provider Demographics
NPI:1902173891
Name:COMMUNITY MEDICINE FOUNDATION
Entity Type:Organization
Organization Name:COMMUNITY MEDICINE FOUNDATION
Other - Org Name:NCFMC PEDITRIC AND ADOLESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-325-7744
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29731-6028
Mailing Address - Country:US
Mailing Address - Phone:803-325-7744
Mailing Address - Fax:803-325-1117
Practice Address - Street 1:225 S HERLONG AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2730
Practice Address - Country:US
Practice Address - Phone:803-325-8742
Practice Address - Fax:803-325-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC-025Medicaid