Healthcare Provider Details

I. General information

NPI: 1437106788
Provider Name (Legal Business Name): CAROLINA COLON & RECTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 SAINT JULIAN PLACE
COLUMBIA SC
29204-2410
US

IV. Provider business mailing address

1730 SAINT JULIAN PL
COLUMBIA SC
29204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-2005
  • Fax: 803-765-0007
Mailing address:
  • Phone: 803-779-2005
  • Fax: 803-765-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH M CORNELL
Title or Position: INSURANCE MANAGER
Credential:
Phone: 803-779-2005