=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003112731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELGIN PODIATRY INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2011
-----------------------------------------------------
Last Update Date | 01/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 RICHLAND MEDICAL PARK DR SUITE 110
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-6849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-807-9388
-----------------------------------------------------
Fax | 803-807-9391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 RICHLAND MEDICAL PARK DR SUITE 110
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-6849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-807-9388
-----------------------------------------------------
Fax | 803-807-9391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHANSINA UM
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 803-586-5737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 571
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------