MEDICARE: ADVANTAGE MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	613535	OTHER		DHEC

General Provider Information

NPI Number	:	1548692478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	9153-C TWO NOTCH ROAD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223
Country	:	US
Telephone Number	:	803-546-1170
Fax Number	:

Provider Business Practice Location Address
First Line	:	9153 TWO NOTCH RD STE C
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5853
Country	:	US
Telephone Number	:	803-546-1170
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TROY D BELTON
Credential	:
Telephone Number	:	803-546-1170

Provider Enumeration Date	:	08/02/2013
Last Update Date	:	08/02/2013

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