Basic Information
| Provider Information | |||||||||
| NPI: | 1659343531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSA | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | CRISTINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 HARDEN STREET EXT | ||||||||
| Address2: | 15 MEDICAL PARK, SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455017 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 MEDICAL PARK SUITE 260 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343822 | ||||||||
| FaxNumber: | 8034343821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 27485 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 274857 | 05 | SC | MEDICAID |