1972693257 NPI number — DR. VINCENT J DEGENHART MD

Table of content: DR. VINCENT J DEGENHART MD (NPI 1972693257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972693257 NPI number — DR. VINCENT J DEGENHART MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGENHART
Provider First Name:
VINCENT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972693257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29202-2344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-254-2394
Provider Business Mailing Address Fax Number:
803-254-7125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 ROBERTS STREET
Provider Second Line Business Practice Location Address:
KERSHAW HEALTH
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-713-2619
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LC0200X , with the licence number:  8917 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 8917 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 8917 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4129441 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 050028863 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 089175 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 77789 . This is a "MEDCOST" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 089175 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2000078 . This is a "CCP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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