=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750544912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIA CARDIOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2008
-----------------------------------------------------
Last Update Date | 07/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 GATEWAY BLVD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29209-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-744-4900
-----------------------------------------------------
Fax | 803-744-2622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4187
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29240-4187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-744-4900
-----------------------------------------------------
Fax | 803-744-2622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | TRACY BUTLER BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-744-2612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------