Provider Demographics
NPI:1881626133
Name:CENTA MEDICAL GROUP PA
Entity type:Organization
Organization Name:CENTA MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALBRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-520-5448
Mailing Address - Street 1:157 CORLEY MILL RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-256-2483
Mailing Address - Fax:803-799-4624
Practice Address - Street 1:157 CORLEY MILL RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-256-2483
Practice Address - Fax:803-799-4624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA1382Medicaid
DC6996OtherRAILROAD MEDICARE
SCGP4644OtherMEDICAID AUDIOLOGY GRP NUMBER
SCGP4644OtherMEDICAID AUDIOLOGY GRP NUMBER