1417031097 NPI number — STATE OF SOUTH CARLINA

Table of content: (NPI 1417031097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417031097 NPI number — STATE OF SOUTH CARLINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF SOUTH CARLINA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SC DEPARTMENT OF PUBLIC HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417031097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 BULL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-898-1553
Provider Business Mailing Address Fax Number:
803-898-2262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 NEWBERRY HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALUDA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-445-2141
Provider Business Practice Location Address Fax Number:
864-445-2020
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERKINS
Authorized Official First Name:
ZANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PATIENT BILLING
Authorized Official Telephone Number:
803-898-1553

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000155822 . This is a "UNISON HEALTH PLAN OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 601246 . This is a "SELECT HEALTH PROVIDER #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DHEC41 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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