Provider Demographics
NPI:1093876435
Name:MARIO S. BANGCO, MD, PA
Entity Type:Organization
Organization Name:MARIO S. BANGCO, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANGCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-347-4473
Mailing Address - Street 1:170 WACCAMAW MEDICAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8965
Mailing Address - Country:US
Mailing Address - Phone:843-347-4473
Mailing Address - Fax:843-347-0290
Practice Address - Street 1:170 WACCAMAW MEDICAL PARK CT
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8965
Practice Address - Country:US
Practice Address - Phone:843-347-4473
Practice Address - Fax:843-347-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC170952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDF8711OtherRAILROAD MEDICARE
NC890195ROtherNC MCAID GROUP #
SCGP4131Medicaid
NC890195ROtherNC MCAID GROUP #
NC890195ROtherNC MCAID GROUP #
SCGP4131Medicaid