1629084132 NPI number — MIDLANDS NEUROLOGY & PAIN ASSOC, P.A

Table of content: (NPI 1629084132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629084132 NPI number — MIDLANDS NEUROLOGY & PAIN ASSOC, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
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:
1629084132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 209
Provider Second Line Business Mailing Address:
MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Provider Business Mailing Address City Name:
STATE PARK
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29147-0209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-0038
Provider Business Mailing Address Fax Number:
803-788-0655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 MILLWOOD AVE
Provider Second Line Business Practice Location Address:
MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29205-1218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-788-0038
Provider Business Practice Location Address Fax Number:
803-788-0655
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OGBURU-OGBONNAYA MD
Authorized Official First Name:
E
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
803-788-0038

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  18323 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 18323 , 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: GP1403 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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