NPIMap

Organization Active NPI

Clemson University

  • Family Nurse Practitioner
  • Walhalla, SC
National Provider Identifier
1093990707
Registry record updated Dec 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
Legal business name
CLEMSON UNIVERSITY
Practice address
200 Booker Dr
Walhalla, SC 29691-2278
Phone
(864) 656-1969
Fax
(843) 985-9562
NPI assigned
Jan 2, 2008
Last updated
Dec 15, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 15, 2025

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

Authorized official

Name
Mr. Ronald W Gimbel, PHD
Title
Director
Phone
(864) 656-1969

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X NU Primary
Mental Health Counselor 101YM0800X NU
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

200 Booker Dr
Walhalla, SC 29691-2278

Mailing address

101 Edwards Hall
Clemson, SC 29634-0001

Other practice location 1

1181 Hutto St
Orangeburg, SC 29118-1467
Phone (803) 516-4227

Other practice location 2

101 Edwards Hall
Clemson, SC 29634-0001
Phone (864) 656-1969

Other identifiers 1

IdentifierTypeStateIssuer
GP1885MedicaidSC

Other names 1

  • Clemson University Clemson Rural Health Other name

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address clemsonruralhealth@clemson.edu Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20121206000375 SC Part B Supplier - Clinic/Group Practice 1850393786 Receives reassigned benefits from 17 practitioners
Practice locations: Clemson, SC; Orangeburg, SC; Walhalla, SC
O20211015002755 SC Part A Provider - Rural Health Clinic 1850393786 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Walhalla, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093990707. Details of each certification follow.

Rural health clinic certification: CCN 873807

Legal name
CLEMSON UNIVERSITY
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 6, 2022
Last certification
Jul 6, 2022
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
200 Booker Dr
Walhalla, SC 29691-2278

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

101 Edwards Hall
Clemson, SC 29634
Phone (864) 656-3076

1521 Perimeter Rd
Clemson, SC 29634
Phone (864) 656-2242

201 Epsilon Zeta Rd
Clemson, SC 29634
Phone (864) 656-3076

Joseph Sullivan Ctr
Clemson, SC 29634
Phone (864) 656-3076

200 Booker Dr
Walhalla, SC 29691
Phone (864) 656-3076

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Clemson University Organization, Walhalla, SC 5% Or Greater Direct Ownership Interest Jul 1, 2019 100%
Ronald W. Gimbel Individual Corporate DirectorDirector, Clemson Rural Health Jul 1, 2019 100%
Michael J. Nebesky Individual OtherDirector, Procurement Jul 1, 2019
Caitlin Moore Individual Operational/Managerial ControlAssoc. Direct., Clinical Operations Jan 1, 2021 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Clemson UniversityWalhalla, SC, CCN 873807 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2019

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 27

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 27

NPI Registry JSON

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

{
    "created_epoch": "1199232000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765756800000",
    "number": "1093990707",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 EDWARDS HALL",
            "city": "CLEMSON",
            "state": "SC",
            "postal_code": "296340001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 BOOKER DR",
            "city": "WALHALLA",
            "state": "SC",
            "postal_code": "296912278",
            "telephone_number": "864-656-1969",
            "fax_number": "843-985-9562"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1181 Hutto St",
            "address_purpose": "LOCATION",
            "city": "Orangeburg",
            "state": "SC",
            "postal_code": "291181467",
            "country_code": "US",
            "telephone_number": "803-516-4227",
            "fax_number": "843-985-9562",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "101 Edwards Hall",
            "address_purpose": "LOCATION",
            "city": "Clemson",
            "state": "SC",
            "postal_code": "296340001",
            "country_code": "US",
            "telephone_number": "864-656-1969",
            "fax_number": "843-985-9562",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CLEMSON UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-02",
        "last_updated": "2025-12-15",
        "certification_date": "2025-12-15",
        "status": "A",
        "authorized_official_last_name": "GIMBEL",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "864-656-1969",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP1885",
            "state": "SC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "clemsonruralhealth@clemson.edu",
            "affiliation": "N",
            "endpointDescription": "provider email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Text",
            "address_1": "101 Edwards Hall",
            "city": "Clemson",
            "state": "SC",
            "country_code": "US",
            "postal_code": "296340001",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Clemson University Clemson Rural Health",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Walhalla, SC

Sources for this page

Verify at the official NPI Registry.