Healthcare Provider Details

I. General information

NPI: 1750210704
Provider Name (Legal Business Name): SOUTH NORTH MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 THAMES VLY
IRMO SC
29063-2469
US

IV. Provider business mailing address

1 THAMES VLY
IRMO SC
29063-2469
US

V. Phone/Fax

Practice location:
  • Phone: 412-273-0996
  • Fax:
Mailing address:
  • Phone: 412-273-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LENSE TESSEMA DURESSO
Title or Position: OWNER
Credential:
Phone: 412-273-0996