Healthcare Provider Details

I. General information

NPI: 1245226133
Provider Name (Legal Business Name): GREGORY S. MANGIONE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RICHLAND MEDICAL PARK DR STE 200
COLUMBIA SC
29203-6882
US

IV. Provider business mailing address

PO BOX 22265
BELFAST ME
04915-4473
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-7303
  • Fax: 803-296-7330
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1284
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: