Healthcare Provider Details

I. General information

NPI: 1770554396
Provider Name (Legal Business Name): JACOB J VANDERSTEENHOVEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 2375
WEST COLUMBIA SC
29171-2375
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-8146
  • Fax: 803-936-8916
Mailing address:
  • Phone: 803-252-1913
  • Fax: 803-252-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number22308
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number22308
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number22308
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: