Basic Information
| Provider Information | |||||||||
| NPI: | 1457675621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SPECIALTY CLINICS - NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MEDICAL PARK | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 MEDICAL PARK | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035456050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2010 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 8035456050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | GP5417 | 05 | SC | MEDICAID | 9482 | 01 | SC | MEDICARE PTAN | OTHER |