=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720310055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN RIDGE GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2010
-----------------------------------------------------
Last Update Date | 02/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 FORUM DR STE 3-255
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-7944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-795-5435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 FORUM DR STE 3-255
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-7944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | THOMAS W NORRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-795-5435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 13651
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------