Provider Demographics
NPI:1871878595
Name:ALLIANCE MEDICAL GROUP
Entity type:Organization
Organization Name:ALLIANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEYVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-225-7317
Mailing Address - Street 1:2179 ASHLEY PHOSPHATE RD STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4180
Mailing Address - Country:US
Mailing Address - Phone:843-225-7317
Mailing Address - Fax:843-225-7318
Practice Address - Street 1:2179 ASHLEY PHOSPHATE RD STE B
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4180
Practice Address - Country:US
Practice Address - Phone:843-225-7317
Practice Address - Fax:843-225-7318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6340Medicaid
SCB214Medicare UPIN