Basic Information
| Provider Information | |||||||||
| NPI: | 1508898958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SPECIALTY CLINICS - SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MEDICAL PARK | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455022 | ||||||||
| FaxNumber: | 8032560977 | ||||||||
| Practice Location | |||||||||
| Address1: | TWO MEDICAL PARK | ||||||||
| Address2: | SUITE300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032562657 | ||||||||
| FaxNumber: | 8034341581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 8032562657 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | PA2960 | 05 | SC | MEDICAID |