Healthcare Provider Details

I. General information

NPI: 1487040192
Provider Name (Legal Business Name): COLUMBIA GASTROENTEROLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PALMETTO HEALTH PKWY SUITE 102
COLUMBIA SC
29212-1753
US

IV. Provider business mailing address

100 PALMETTO HEALTH PKWY SUITE 102
COLUMBIA SC
29212-1753
US

V. Phone/Fax

Practice location:
  • Phone: 803-907-7600
  • Fax:
Mailing address:
  • Phone: 803-907-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number19286
License Number StateSC

VIII. Authorized Official

Name: MARGOT CARROLL
Title or Position: ADMINSTRATIVE COORDINATOR
Credential:
Phone: 803-799-4800