Healthcare Provider Details

I. General information

NPI: 1124070826
Provider Name (Legal Business Name): SUMTER SURGICAL ASSOCIATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N SUMTER ST SUITE 300
SUMTER SC
29150-4972
US

IV. Provider business mailing address

115 N SUMTER ST STE 300
SUMTER SC
29150-4972
US

V. Phone/Fax

Practice location:
  • Phone: 803-778-0212
  • Fax: 803-775-7258
Mailing address:
  • Phone: 803-778-0212
  • Fax: 803-775-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: HENRY P MOSES
Title or Position: PHYSICIAN-PARTNER
Credential: MD
Phone: 803-778-0212