MEDICARE: EQUILIBRIUM DIABETES CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	28953	SC

General Provider Information

NPI Number	:	1295156404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EQUILIBRIUM DIABETES CENTER, LLC

Provider Business Mailing Address
First Line	:	622 OLD TROLLEY RD
Second Line	:	SUITE 102
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-5674
Country	:	US
Telephone Number	:	843-871-7979
Fax Number	:	843-871-8282

Provider Business Practice Location Address
First Line	:	1342 ELLISON RUN
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-8285
Country	:	US
Telephone Number	:	843-364-6695
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ORLIN SERGEV
Credential	:	MD
Telephone Number	:	843-871-7979

Provider Enumeration Date	:	12/16/2013
Last Update Date	:	12/16/2013

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