NPIMap

Organization Active NPI

Medical University Hospital Authority

Doing business as MUSC Health Primary Care - Ron McNair Blvd

  • Rural Health Clinic/Center
  • Lake City, SC
National Provider Identifier
1063149748
Registry record updated Oct 13, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Doing business as
MUSC Health Primary Care - Ron McNair Blvd
Practice address
276 N Ron McNair Blvd
Lake City, SC 29560-2462
Phone
(843) 792-1414
NPI assigned
Aug 3, 2022
Last updated
Oct 13, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 13, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Karyn Rae
Title
Chief Payor Relations and Reimburse
Phone
(843) 876-1344

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

276 N Ron McNair Blvd
Lake City, SC 29560-2462

Mailing address

PO Box 23467
New York, NY 10087-3467
Phone (843) 792-6200

Other names 1

  • MUSC Health Primary Care - Ron McNair Blvd Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220830000642 SC Part A Provider - Rural Health Clinic 1557268950 Practice locations: Lake City, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063149748. Details of each certification follow.

Rural health clinic certification: CCN 423430

Legal name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Doing business as
MUSC HEALTH PRIMARY CARE - RON MCNAIR BLVD
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 1, 2005
Last certification
Nov 24, 2020
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
276 N Ron McNair Blvd
Lake City, SC 29560-2462
Related CCNs
420051

Facilities connected through Provider of Services related, parent or unit certification numbers.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D0251889Medical University Hospital Authority Dba Musc276 N Ron McNair Blvd, Lake City, SC 29560Certificate of waiverSep 30, 2026

National Provider Directory

National Provider Directory
Tax ID family
Musc Hospital71 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 18

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 18

Locations

276 N Ron McNair Blvd
Lake City, SC 29560
Phone (843) 394-1051

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lisa M Goodlett Individual Corporate OfficerCfo Oct 1, 2022 100%
Sonya Floyd Individual W-2 Managing EmployeeManager, Provider Enrollment & C Oct 1, 2022 100%
Karyn Rae Individual Corporate DirectorChief, Payor Relations & Reimbur Oct 1, 2022 100%

All facility ownership & control disclosures 11

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tidelands Waccamaw Community HospitalMurrells Inlet, SC, CCN 420098 Hospital Operational/Managerial Control Oct 1, 2025
Tidelands Georgetown Memorial HospitalGeorgetown, SC, CCN 420020 Hospital Operational/Managerial Control Oct 1, 2025
Musc Health Lancaster Medical CenterLancaster, SC, CCN 429803 Hospital Operational/Managerial Control (100%) Mar 1, 2019
Musc Health Lancaster Rehabilitation CenterLancaster, SC, CCN 42T036 Hospital Operational/Managerial Control (100%) Mar 1, 2019
Tidelands Georgetown Memorial HospitalGeorgetown, SC, CCN 42U020 Hospital Operational/Managerial Control Oct 1, 2025
Tidelands Health Family Medicine at GeorgetownGeorgetown, SC, CCN 428958 Rural health clinic Operational/Managerial Control Oct 1, 2020
Tidelands Health Family Medicine at HemingwayHemingway, SC, CCN 423859 Rural health clinic Operational/Managerial Control Oct 1, 2025
Tidelands Health Family MedicineAndrews, SC, CCN 423970 Rural health clinic Operational/Managerial Control Oct 1, 2025
Tidelands Health Family Medicine at Pawleys IslandPawleys Island, SC, CCN 423870 Rural health clinic Operational/Managerial Control Oct 1, 2025
Musc Health Primary Care - Thurgood Marshall BlvdKingstree, SC, CCN 423448 Rural health clinic Operational/Managerial Control (100%) Dec 1, 2022
Musc Community PhysiciansBranchville, SC, CCN 423856 Rural health clinic Operational/Managerial Control (100%) Aug 1, 2021

Change-of-ownership history 1

DateEventCounterparty
Oct 1, 2022 Change of OwnershipThis provider was the buyer Pee Dee Family PracticeCCN 423430, SC, NPI 1437256757

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1659484800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665619200000",
    "number": "1063149748",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23467",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100873467",
            "telephone_number": "843-792-6200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "276 N RON MCNAIR BLVD",
            "city": "LAKE CITY",
            "state": "SC",
            "postal_code": "295602462",
            "telephone_number": "843-792-1414"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL UNIVERSITY HOSPITAL AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-08-03",
        "last_updated": "2022-10-13",
        "certification_date": "2022-10-13",
        "status": "A",
        "authorized_official_last_name": "RAE",
        "authorized_official_first_name": "KARYN",
        "authorized_official_title_or_position": "CHIEF PAYOR RELATIONS AND REIMBURSE",
        "authorized_official_telephone_number": "843-876-1344"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MUSC Health Primary Care - Ron McNair Blvd",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake City, SC

Sources for this page

Verify at the official NPI Registry.