1467407155 NPI number — EDISTO OBGYN PA

Table of content: (NPI 1467407155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467407155 NPI number — EDISTO OBGYN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDISTO OBGYN PA
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467407155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1175 COOK RD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-536-9390
Provider Business Mailing Address Fax Number:
803-533-0911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1175 COOK RD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-536-9390
Provider Business Practice Location Address Fax Number:
803-533-0911
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEGEN
Authorized Official First Name:
JEROME
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-536-9390

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  07054 , 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: 070540 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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