Provider Demographics
NPI:1073072468
Name:NEWBERRY SURGICAL LLC
Entity Type:Organization
Organization Name:NEWBERRY SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:CANTEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-278-4819
Mailing Address - Street 1:3611 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-3418
Mailing Address - Country:US
Mailing Address - Phone:912-278-4819
Mailing Address - Fax:
Practice Address - Street 1:2660 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2912
Practice Address - Country:US
Practice Address - Phone:912-278-4819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC188175Medicaid