Provider Demographics
NPI:1447637798
Name:UNIVERSITY OF SOUTH CAROLINA
Entity type:Organization
Organization Name:UNIVERSITY OF SOUTH CAROLINA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:803-777-3861
Mailing Address - Street 1:1600 HAMPTON ST FL 6
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8301 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3245
Practice Address - Country:US
Practice Address - Phone:803-935-5604
Practice Address - Fax:803-935-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDEC100Medicaid