Provider Demographics
NPI:1730137092
Name:CHESTERFIELD-MARLBORO, LP
Entity type:Organization
Organization Name:CHESTERFIELD-MARLBORO, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-398-7108
Mailing Address - Street 1:711 CHESTERFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-7002
Mailing Address - Country:US
Mailing Address - Phone:843-320-3304
Mailing Address - Fax:843-320-3480
Practice Address - Street 1:711 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7002
Practice Address - Country:US
Practice Address - Phone:843-320-3304
Practice Address - Fax:843-320-3480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC367500000X, 207P00000X
207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012AVMedicaid
SCCG3996OtherRR MEDICARE
SC400621Medicaid
NC890769BMedicaid
SC400621Medicaid
NC89012AVMedicaid
SCCD6809Medicare PIN