MEDICARE: CONCIERGE MEDICAL LAB

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207RI0001X	Clinical & Laboratory Immunology (Internal Medicine) Physician
2	246RM2200X	Medical Laboratory Technician
3	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1366220758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCIERGE MEDICAL LAB

Provider Business Mailing Address
First Line	:	PO BOX 23328
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29224-3328
Country	:	US
Telephone Number	:	803-722-4988
Fax Number	:	803-656-8135

Provider Business Practice Location Address
First Line	:	110 WILDEWOOD PARK DR STE A
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-4301
Country	:	US
Telephone Number	:	803-722-9888
Fax Number	:	803-656-8135

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	SARAH DOCTOR-GREENWADE
Credential	:
Telephone Number	:	803-722-4988

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	05/28/2024

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Directions to “CONCIERGE MEDICAL LAB ” Practice Location

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