1861520157 NPI number — SUMTER PODIATRY SERVICES PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861520157 NPI number — SUMTER PODIATRY SERVICES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMTER PODIATRY SERVICES 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:
1861520157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1485
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29151-1485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-469-9255
Provider Business Mailing Address Fax Number:
803-469-9253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 HARDEE CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-1893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-469-9255
Provider Business Practice Location Address Fax Number:
803-469-9253
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
EMANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT PODIATRIST
Authorized Official Telephone Number:
803-469-9255

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PDO886 , 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: GP9925 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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