Healthcare Provider Details

I. General information

NPI: 1508958216
Provider Name (Legal Business Name): APEXCARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 HIGHWAY 1 S SUITE 200
LUGOFF SC
29078-8966
US

IV. Provider business mailing address

1165 HIGHWAY 1 S SUITE 200
LUGOFF SC
29078-8966
US

V. Phone/Fax

Practice location:
  • Phone: 803-408-0225
  • Fax: 803-408-0729
Mailing address:
  • Phone: 803-408-0225
  • Fax: 803-408-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20381
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20381
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier203817
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: DR. OLAJIDE A. BALOGUN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 803-408-0225