NPIMap

Organization Active NPI

Caresouth Carolina Inc

  • Federally Qualified Health Center (FQHC)
  • Bennettsville, SC
National Provider Identifier
1639458672
Registry record updated Mar 21, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CARESOUTH CAROLINA INC
Practice address
210 W Main St
Bennettsville, SC 29512-3122
Phone
(843) 479-1200
Fax
(843) 479-1230
NPI assigned
Aug 9, 2011
Last updated
Mar 21, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2012

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

Authorized official

Name
Ann M Lewis
Title
Ceo
Phone
(843) 857-0111

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

210 W Main St
Bennettsville, SC 29512-3122

Mailing address

PO Box 1090
Hartsville, SC 29551-1090
Phone (843) 857-0111

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040511000280 SC Part B Supplier - Clinic/Group Practice 1052221314 Receives reassigned benefits from 95 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Society Hill, SC; MC Coll, SC; Latta, SC; Lake View, SC; Hartsville, SC; Dillon, SC; Chesterfield, SC; Cheraw, SC…
O20110923000018 SC Part A Provider - Federally Qualified Health Center (FQHC) 1052221314 Practice locations: Bennettsville, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639458672. Details of each certification follow.

Federally qualified health center certification: CCN 421948

Legal name
CARESOUTH CAROLINA INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 17, 2011
Last certification
Nov 17, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 5, 1978 in SC
Enrollment address
210 West Main Street
Bennettsville, SC 29512-1076

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 11

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

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
42D1024216Caresouth Carolina Pediatrics210 West Main Street, Bennettsville, SC 29512Certificate of waiverApr 5, 2028

National Provider Directory

National Provider Directory
Tax ID family
Pee Dee Community Healt26 organizations share this tax ID, including this one

Other organizations with this tax ID 25

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

View all 25

Locations

210 W Main St
Bennettsville, SC 29512
Phone (843) 332-5121

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Mary J Garvin Individual Corporate OfficerBoard Member Apr 7, 1978
Ennis R Bryant Individual Corporate OfficerBoard Member-Vice Chairperson Jan 1, 1992
Flossie W Bartell Individual Corporate OfficerBoard Member-Treasurer Jun 26, 2003
Teresa Gainey Individual Corporate OfficerBoard Member Dec 19, 2019
Ann Marie Lewis Individual Corporate OfficerCeo Apr 5, 1978
Corporate DirectorCeo Apr 5, 1978
Operational/Managerial ControlCeo Apr 5, 1978
Trudy Drawhorn Individual Corporate OfficerBoard Member Jul 27, 2017
Earnestine S Powe Individual Corporate OfficerBoard Member/Assistant Secretary Jan 1, 1984
Patricia M Henegan Individual Corporate Officer Jul 27, 2017
Dorothy S Joyner Individual Corporate OfficerBoard Member Jan 1, 1996
Gene T Harper Individual Corporate OfficerBoard Member Oct 16, 2023
Bonnie M Seals Individual Corporate OfficerBoard Member-Secretary Jan 1, 1996
Mary D Legrant Individual Corporate OfficerBoard Member Jan 1, 1996
Jay S Hodge Individual Corporate OfficerBoard Member-Chairperson Jan 1, 1998

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1312848000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1332288000000",
    "number": "1639458672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1090",
            "city": "HARTSVILLE",
            "state": "SC",
            "postal_code": "295511090",
            "telephone_number": "843-857-0111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "210 W MAIN ST",
            "city": "BENNETTSVILLE",
            "state": "SC",
            "postal_code": "295123122",
            "telephone_number": "843-479-1200",
            "fax_number": "843-479-1230"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CARESOUTH CAROLINA INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-09",
        "last_updated": "2012-03-21",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "ANN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "843-857-0111"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bennettsville, SC

Sources for this page

Verify at the official NPI Registry.