Healthcare Provider Details

I. General information

NPI: 1699280644
Provider Name (Legal Business Name): MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 MILLWOOD AVE
COLUMBIA SC
29205-1218
US

IV. Provider business mailing address

PO BOX 209
STATE PARK SC
29147-0209
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number18323
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number18323
License Number StateSC

VIII. Authorized Official

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