MEDICARE: MIDLANDS ELECTRODIAGNOSTIC SERVICES, 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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1952502635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLANDS ELECTRODIAGNOSTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	296 SHERINGHAM RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8679
Country	:	US
Telephone Number	:	803-401-1372
Fax Number	:

Provider Business Practice Location Address
First Line	:	421 HULON LN
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-4832
Country	:	US
Telephone Number	:	803-739-1315
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JENNIFER L GRAY
Credential	:
Telephone Number	:	803-401-1372

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	08/22/2020

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