Basic Information
Provider Information
NPI: 1528037850
EntityType: 2
ReplacementNPI:  
OrganizationName: SUMTER OBGYN PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1469
Address2:  
City: SUMTER
State: SC
PostalCode: 291511469
CountryCode: US
TelephoneNumber: 8037758351
FaxNumber: 8037732635
Practice Location
Address1: 115 N SUMTER ST
Address2: SUITE 200
City: SUMTER
State: SC
PostalCode: 291504972
CountryCode: US
TelephoneNumber: 8037758351
FaxNumber: 8037732635
Other Information
ProviderEnumerationDate: 03/17/2006
LastUpdateDate: 10/29/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SCURRY
AuthorizedOfficialFirstName: TRACIE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CREDENTIALING/INS/BILLING
AuthorizedOfficialTelephone: 8037758351
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207V00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansObstetrics & Gynecology 

ID Information
IDTypeStateIssuerDescription
PA134605SC MEDICAID


Home