Healthcare Provider Details

I. General information

NPI: 1912237074
Provider Name (Legal Business Name): MIDLANDS UROLOGICAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 SUMMERPLACE DR
WEST COLUMBIA SC
29169-3058
US

IV. Provider business mailing address

139 SUMMERPLACE DR
WEST COLUMBIA SC
29169-3058
US

V. Phone/Fax

Practice location:
  • Phone: 803-796-9968
  • Fax: 803-753-9105
Mailing address:
  • Phone: 803-796-9968
  • Fax: 803-753-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA M WATSON
Title or Position: PRACTICE ADMINISTRATOR
Credential: CMM
Phone: 803-796-9968