Healthcare Provider Details

I. General information

NPI: 1407821721
Provider Name (Legal Business Name): COLUMBIA NEPHROLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PARK CENTRAL DR 200
COLUMBIA SC
29203-6469
US

IV. Provider business mailing address

121 PARK CENTRAL DR 200
COLUMBIA SC
29203-6469
US

V. Phone/Fax

Practice location:
  • Phone: 803-252-9907
  • Fax: 803-252-9906
Mailing address:
  • Phone: 803-252-9907
  • Fax: 803-252-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateSC

VIII. Authorized Official

Name: MR. CARL B SHEALY
Title or Position: PRESIDENT
Credential: MD
Phone: 803-252-9907