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General NPI Number Information
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NPI Number | 1265615447
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Entity Type | Organization
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Legal Business Name | THE BURNSIDE CLINIC
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 12/11/2007
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Provider Practice Location Address
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Address Line | 1011 ARCADIA LAKES DR
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City | COLUMBIA
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State | SC
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Zip | 29206-1324
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Country | US
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Telephone | 803-787-1113
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Fax | 803-181-1704
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Provider Business Mailing Address
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Address Line | 1011 ARCADIA LAKES DR
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City | COLUMBIA
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State | SC
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Zip | 29206-1324
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Country | US
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Telephone | 803-787-1113
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Fax | 803-181-1704
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Authorized Official
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Title or Position | PRIVATE PHYSICIAN/OWNER
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Name | DR. ALFRED FLOURNOY BURNSIDE JR.
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Credential | M.D.
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Telephone | 803-787-1113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0334
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License Number State | SC
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