=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700983798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA INTINTOLA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 STUART ST MONCRIEF ARMY HOSPITAL; ATTN: MCXL-PQ( CREDENTIALS)
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29207-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-751-2618
-----------------------------------------------------
Fax | 803-751-2689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 STUART ST MONCRIEF ARMY HOSPITAL; ATTN: MCXL-PQ( CREDENTIALS)
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29207-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-751-2618
-----------------------------------------------------
Fax | 803-751-2689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2004009608
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------