Basic Information
Provider Information | |||||||||
NPI: | 1174551253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUBER | ||||||||
FirstName: | DEALVA | ||||||||
MiddleName: | TAUNDOLYN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SUBER-MITCHELL | ||||||||
OtherFirstName: | DEALVA | ||||||||
OtherMiddleName: | TAUNDOLYN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 6439 GARNERS FERRY RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292091638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037764000 | ||||||||
FaxNumber: | 8036958062 | ||||||||
Practice Location | |||||||||
Address1: | 6439 GARNERS FERRY RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292091638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037764000 | ||||||||
FaxNumber: | 8036958062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 02/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 15386 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0100X | 15386 | SC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 153862 | 05 | SC |   | MEDICAID |