Healthcare Provider Details

I. General information

NPI: 1477506459
Provider Name (Legal Business Name): JAROSLAW M AMBROZIAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEREMY M AMBROZIAK MD

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 LAUREL ST 103
COLUMBIA SC
29204-2038
US

IV. Provider business mailing address

2750 LAUREL ST 103
COLUMBIA SC
29204-2023
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-5171
  • Fax: 803-779-7403
Mailing address:
  • Phone: 803-254-5171
  • Fax: 803-779-7403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21987
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: