Provider Demographics
NPI:1073868600
Name:CHERRYDALE MEDICAL PRACTICE PC
Entity type:Organization
Organization Name:CHERRYDALE MEDICAL PRACTICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-918-4600
Mailing Address - Street 1:6 SPOLETO CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-3062
Mailing Address - Country:US
Mailing Address - Phone:864-467-2005
Mailing Address - Fax:
Practice Address - Street 1:3213 N PLEASANTBURG DR
Practice Address - Street 2:STE E2
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2900
Practice Address - Country:US
Practice Address - Phone:864-467-2005
Practice Address - Fax:864-467-2089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care