Healthcare Provider Details

I. General information

NPI: 1174524821
Provider Name (Legal Business Name): LISA LEIGH CORUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 09/27/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 VILLAGE PARK DR
ORANGEBURG SC
29118-2457
US

IV. Provider business mailing address

1750 VILLAGE PARK DR
ORANGEBURG SC
29118-2457
US

V. Phone/Fax

Practice location:
  • Phone: 803-395-4160
  • Fax: 803-531-8810
Mailing address:
  • Phone: 803-395-4160
  • Fax: 803-531-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013-02331
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33949
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18752
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: