MEDICARE: SOUTHEASTERN EAR NOSE THROAT ALLERGY AND SLEEP DISORDERS INSTITUTE

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	207YS0012X	Sleep Medicine (Otolaryngology) Physician	28760	SC
2	207YS0123X	Facial Plastic Surgery Physician	28760	SC
3	207YX0602X	Otolaryngic Allergy Physician	28760	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770809428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN EAR NOSE THROAT ALLERGY AND SLEEP DISORDERS INSTITUTE

Provider Business Mailing Address
First Line	:	1040 PINNACLE POINT DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5735
Country	:	US
Telephone Number	:	803-509-7200
Fax Number	:	803-509-7213

Provider Business Practice Location Address
First Line	:	1040 PINNACLE POINT DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5735
Country	:	US
Telephone Number	:	803-509-7200
Fax Number	:	803-509-7213

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHAD B GUNNLAUGSSON
Credential	:	MD
Telephone Number	:	803-509-7200

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	03/07/2023

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