Healthcare Provider Details

I. General information

NPI: 1467406918
Provider Name (Legal Business Name): SOUTH CAROLINA ONCOLOGY ASSOC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 STONERIDGE DR SOUTH CAROLINA ONCOLOGY ASSOC
COLUMBIA SC
29210
US

IV. Provider business mailing address

PO BOX 2046
WEST COLUMBIA SC
29171
US

V. Phone/Fax

Practice location:
  • Phone: 803-461-3000
  • Fax: 803-461-4917
Mailing address:
  • Phone: 803-461-3000
  • Fax: 803-461-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRED J KUDRIK
Title or Position: PRESIDENT
Credential: MD
Phone: 803-461-3000