Provider Demographics
NPI:1215047535
Name:SOUTH CHARLESTON MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTH CHARLESTON MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:937-398-0051
Mailing Address - Street 1:1176 E HOME RD
Mailing Address - Street 2:SUITE O
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2726
Mailing Address - Country:US
Mailing Address - Phone:937-398-0051
Mailing Address - Fax:937-398-0054
Practice Address - Street 1:1176 E HOME RD
Practice Address - Street 2:SUITE O
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2726
Practice Address - Country:US
Practice Address - Phone:937-398-0051
Practice Address - Fax:937-398-0054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9344761Medicare ID - Type Unspecified