Healthcare Provider Details

I. General information

NPI: 1134153083
Provider Name (Legal Business Name): SOUTH CAROLINA ENT ALLERGY & SLEEP MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 EXCHANGE DR
LUGOFF SC
29078-9198
US

IV. Provider business mailing address

PO BOX 520
LUGOFF SC
29078-0520
US

V. Phone/Fax

Practice location:
  • Phone: 803-408-3277
  • Fax: 803-408-3277
Mailing address:
  • Phone: 803-408-3277
  • Fax: 803-408-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: PAMELA LEA KIRBY
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 803-424-2207