Basic Information
| Provider Information | |||||||||
| NPI: | 1942406434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SPECIALTY CLINICS - OPHTHALMOLOGY | ||||||||
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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: | 8035455022 | ||||||||
| FaxNumber: | 8032560977 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346836 | ||||||||
| FaxNumber: | 8034341581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8034346836 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 0368630003 | 01 | SC | MEDICARE DME | OTHER |