Healthcare Provider Details

I. General information

NPI: 1164537635
Provider Name (Legal Business Name): SUMTER UROLOGICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W WESMARK BLVD
SUMTER SC
29150-1983
US

IV. Provider business mailing address

410 W WESMARK BLVD
SUMTER SC
29150-1983
US

V. Phone/Fax

Practice location:
  • Phone: 803-469-4402
  • Fax: 803-469-4473
Mailing address:
  • Phone: 803-469-4402
  • Fax: 803-469-4473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT LEE
Title or Position: PRESEDENT
Credential: M.D.
Phone: 803-469-4402