Provider Demographics
NPI:1023041118
Name:DE PINA, MANUEL ANTONIA (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ANTONIA
Last Name:DE PINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6307
Mailing Address - Fax:
Practice Address - Street 1:1025 VERDAE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-286-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20807207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC208073Medicaid
SCP00095900OtherMEDICARE RAILROAD
SCH13719Medicare UPIN
SC17162OtherUNISON
SC57-6007863OtherBCBS
SC25-N066OtherSC CONTROLLED SUBST
SCP00095900OtherMEDICARE RAILROAD
SC20031678OtherSELECT HEALTH GRP
SC208073Medicaid
SCH13719Medicare UPIN