Provider Demographics
NPI:1093146466
Name:ECP SOUTH CAROLINA, P.A.
Entity Type:Organization
Organization Name:ECP SOUTH CAROLINA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEESON-WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-412-0446
Mailing Address - Street 1:PO BOX 896129
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4212
Practice Address - Country:US
Practice Address - Phone:864-412-0446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6356Medicaid
NC1093146466Medicaid
NCD521Medicare PIN
NC1093146466Medicaid