Healthcare Provider Details

I. General information

NPI: 1689136475
Provider Name (Legal Business Name): PRUDENCE NASSEM IPAYE-ADEBIYI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHLAND MEDICAL PARK DR STE 100
COLUMBIA SC
29203-6834
US

IV. Provider business mailing address

300 E MCBEE AVE
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6095
  • Fax: 803-758-0120
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number90102
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number39801
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90102
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39801
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number90102
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: