1649875816 NPI number — PRIVIA MEDICAL GROUP SOUTH CAROLINA, LLC

Table of content: (NPI 1649875816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649875816 NPI number — PRIVIA MEDICAL GROUP SOUTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIVIA MEDICAL GROUP SOUTH CAROLINA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1649875816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 DOCTORS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29605-4266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-572-7001
Provider Business Mailing Address Fax Number:
864-412-0436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 DOCTORS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-4266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-572-7001
Provider Business Practice Location Address Fax Number:
864-412-0436
Provider Enumeration Date:
12/03/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
OSBORNE
Authorized Official Title or Position:
MD-GREENVILLE ENT & ALLERGY ASSOC.
Authorized Official Telephone Number:
833-450-0514

Provider Taxonomy Codes

  • Taxonomy code: 207YP0228X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0602X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)