Basic Information
| Provider Information | |||||||||
| NPI: | 1437106788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA COLON & RECTAL | ||||||||
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| OtherOrganizationName: | CCRS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037792005 | ||||||||
| FaxNumber: | 8037650007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 SAINT JULIAN PLACE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037792005 | ||||||||
| FaxNumber: | 8037650007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | CORNELL | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8037792005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | PC0691 | 05 | SC | MEDICAID |