Provider Demographics
NPI:1124313101
Name:CAROLINA GERIATRIC SPECIALISTS, LLC
Entity type:Organization
Organization Name:CAROLINA GERIATRIC SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MACDONALD
Authorized Official - Middle Name:MAYES
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-775-1001
Mailing Address - Street 1:244 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4256
Mailing Address - Country:US
Mailing Address - Phone:803-775-1001
Mailing Address - Fax:803-774-1012
Practice Address - Street 1:244 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4256
Practice Address - Country:US
Practice Address - Phone:803-775-1001
Practice Address - Fax:803-774-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22541174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1265418164Medicaid
SC1265418164Medicaid
SCH675200281Medicare PIN