Healthcare Provider Details

I. General information

NPI: 1407012701
Provider Name (Legal Business Name): BAMBERG EMERGENCY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 NORTH ST
BAMBERG SC
29003-1330
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 803-245-4321
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SYLVAN M WALLER
Title or Position: PRESIDENT
Credential: MD
Phone: 800-893-9698