MEDICARE: PRIMARY CARE ENDOSCOPY OF COLUMBIA, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1295988053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE ENDOSCOPY OF COLUMBIA, LLC

Provider Business Mailing Address
First Line	:	3100 W END AVE
Second Line	:	SUITE 150
City	:	NASHVILLE
State	:	TN
Zip	:	37203-1320
Country	:	US
Telephone Number	:	615-345-6900
Fax Number	:	615-345-6905

Provider Business Practice Location Address
First Line	:	1735 TAYLOR ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3452
Country	:	US
Telephone Number	:	803-254-8449
Fax Number	:	803-254-8984

Authorized Official
Title or Position	:	PRESIDENT, BOARD OF MANAGERS
Name	:	DAVID WILLIAM HOLST
Credential	:
Telephone Number	:	615-345-6899

Provider Enumeration Date	:	10/24/2008
Last Update Date	:	10/24/2008

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