Basic Information
| Provider Information | |||||||||
| NPI: | 1891938734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIRINVARAVONG | ||||||||
| FirstName: | SIRINART | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 648 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292030648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035401000 | ||||||||
| FaxNumber: | 8035401011 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035401000 | ||||||||
| FaxNumber: | 8035401011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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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 | 207RE0101X | 34322 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207R00000X | 34322 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 343220 | 05 | SC | MEDICAID |