Basic Information
| Provider Information | |||||||||
| NPI: | 1679886881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036834 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | RALEY | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8035455354 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4273 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.