Healthcare Provider Details

I. General information

NPI: 1972791200
Provider Name (Legal Business Name): COLUMBIA COLON AND RECTAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BLANDING ST SUITE 2
COLUMBIA SC
29201-2922
US

IV. Provider business mailing address

1415 BLANDING ST SUITE 2
COLUMBIA SC
29201-2922
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-0819
  • Fax: 803-779-9476
Mailing address:
  • Phone: 803-779-0819
  • Fax: 803-779-9476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number13344
License Number StateSC

VIII. Authorized Official

Name: DIANE K ALBERT
Title or Position: BUSINESS MANAGER
Credential:
Phone: 803-779-0819