Basic Information
Provider Information | |||||||||
NPI: | 1215912548 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COURBAN | ||||||||
FirstName: | CHRISTO | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: | CHRISTO COURBAN EMERGENCY MEDICINE | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433478015 | ||||||||
FaxNumber: | 8432345017 | ||||||||
Practice Location | |||||||||
Address1: | 2829 E HIGHWAY 76 | ||||||||
Address2: |   | ||||||||
City: | MULLINS | ||||||||
State: | SC | ||||||||
PostalCode: | 295746035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434312000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2005 | ||||||||
LastUpdateDate: | 01/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 159466 | MA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 28270 | SC | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 282704 | 05 | SC |   | MEDICAID |