MEDICARE: EQUILIBRIUM ENDOCRINOLOGY, PA

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	:	1962658740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EQUILIBRIUM ENDOCRINOLOGY, PA

Provider Business Mailing Address
First Line	:	622 TROLLEY RD
Second Line	:	SUITE 102
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-5674
Country	:	US
Telephone Number	:	843-851-3727
Fax Number	:

Provider Business Practice Location Address
First Line	:	622 TROLLEY RD
Second Line	:	SUITE 102
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-5674
Country	:	US
Telephone Number	:	843-851-3727
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ORLIN SERGEV
Credential	:	MD, PHD
Telephone Number	:	843-851-3727

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	10/16/2008

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