Basic Information
Provider Information | |||||||||
NPI: | 1346761210 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DILLARD COX | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | FOSTER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, CPNP-PC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3555 HARDEN STREET EXT | ||||||||
Address2: | SUITE 300 | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292036894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035455017 | ||||||||
FaxNumber: | 8032553451 | ||||||||
Practice Location | |||||||||
Address1: | 9 MEDICAL PARK SUITE 230 | ||||||||
Address2: | USC PALMETTO HEALTH PEDIATRIC ENDOCRINOLOGY | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 29203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034347990 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2017 | ||||||||
LastUpdateDate: | 04/02/2018 | ||||||||
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 | 363L00000X | 20992 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | NP4710 | 05 | SC |   | MEDICAID |