Healthcare Provider Details

I. General information

NPI: 1629084132
Provider Name (Legal Business Name): MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 MILLWOOD AVE MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
COLUMBIA SC
29205-1218
US

IV. Provider business mailing address

PO BOX 209 MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
STATE PARK SC
29147-0209
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-0038
  • Fax: 803-788-0655
Mailing address:
  • Phone: 803-788-0038
  • Fax: 803-788-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number18323
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number18323
License Number StateSC

VIII. Authorized Official

Name: E OGBURU-OGBONNAYA MD
Title or Position: PRESIDENT CEO
Credential: MD
Phone: 803-788-0038