NPIMap

Organization Active NPI

Allendale County Hospital Board

Doing business as Allendale County Hospital

  • General Acute Care Hospital
  • Fairfax, SC
National Provider Identifier
1609866912
Registry record updated Apr 23, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
Legal business name
ALLENDALE COUNTY HOSPITAL BOARD
Doing business as
Allendale County Hospital
Practice address
1787 Allendale Fairfax Hwy
Fairfax, SC 29827-9133
Phone
(803) 632-3311
Fax
(803) 632-3415
NPI assigned
Oct 27, 2005
Last updated
Apr 23, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
ALLENDALE COUNTY HOSPITAL BOARDAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 23, 2019

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

Authorized official

Name
Teresa H Hicks
Title
Cfo
Phone
(803) 632-3311

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X Primary
Critical Access Hospital 282NC0060X HTL-041 SC

Addresses

Primary practice location

1787 Allendale Fairfax Hwy
Fairfax, SC 29827-9133

Mailing address

1787 Allendale Fairfax Hwy
P. O. Box 218
Fairfax, SC 29827-9133
Phone (803) 632-3311

Other identifiers 3

IdentifierTypeStateIssuer
300958MedicaidSC
100895MedicaidSC
3389MedicaidSC

Other names 1

  • Allendale County Hospital Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120302000200 SC Part A Provider - Critical Access Hospital 2567371610 Receives reassigned benefits from 62 practitioners
Practice locations: Fairfax, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609866912. Details of each certification follow.

Hospital certification: CCN 421300

Legal name
ALLENDALE COUNTY HOSPITAL BOARD
Doing business as
ALLENDALE COUNTY HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Oct 1, 2001
Last certification
Jan 5, 2023
Beds
25
Ownership / control type
Local
Organization structure
OtherNon-profit
Enrollment address
1787 Allendale Fairfax Hwy
Fairfax, SC 29827-9133
Other Hospital Practice Location

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

Other NPIs with the same Medicare PAC ID 5

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Allendale County HospitalCCN 421300 · All quality measures
Type
Critical Access Hospitals
Ownership
Government - Local
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Allendale County Hospital7 organizations share this tax ID, including this one
Part of
Allendale County Hospital

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

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
Teresa Hicks Individual W-2 Managing EmployeeCfo Sep 24, 2014
Allendale County Hospital Board Organization, Fairfax, SC Non-profit Operational/Managerial Control Jan 1, 1996 100%
Lari Gooding Individual Corporate OfficerCeo/Administrator Jan 1, 2015 100%

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Allendale County HospitalFairfax, SC, CCN 42Z300 Hospital Operational/Managerial Control (100%) Jan 1, 1996
John Edward Harter Nursing CenterFairfax, SC, CCN 425103 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Nov 1, 1997
Nov 1, 1967
Allendale County Hospital BoardFairfax, SC, CCN 423428 Rural health clinic Operational/Managerial Control (100%) Apr 1, 2000

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 65

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 65

Affiliated clinicians 55

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 55

NPI Registry JSON

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

{
    "created_epoch": "1130371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1555977600000",
    "number": "1609866912",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1787 ALLENDALE FAIRFAX HWY",
            "address_2": "P. O. BOX 218",
            "city": "FAIRFAX",
            "state": "SC",
            "postal_code": "298279133",
            "telephone_number": "803-632-3311",
            "fax_number": "803-632-3415"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1787 ALLENDALE FAIRFAX HWY",
            "city": "FAIRFAX",
            "state": "SC",
            "postal_code": "298279133",
            "telephone_number": "803-632-3311",
            "fax_number": "803-632-3415"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALLENDALE COUNTY HOSPITAL BOARD",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ALLENDALE COUNTY HOSPITAL BOARD",
        "enumeration_date": "2005-10-27",
        "last_updated": "2019-04-23",
        "status": "A",
        "authorized_official_last_name": "HICKS",
        "authorized_official_first_name": "TERESA",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "803-632-3311"
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "SC",
            "license": "HTL-041",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300958",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100895",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3389",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Allendale County Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Allendale County Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fairfax, SC

Sources for this page

Verify at the official NPI Registry.