Provider Demographics
NPI:1114995974
Name:MEDICAL PARK OB-GYN, PA
Entity Type:Organization
Organization Name:MEDICAL PARK OB-GYN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:POPOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-254-4110
Mailing Address - Street 1:9 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6873
Mailing Address - Country:US
Mailing Address - Phone:803-254-4110
Mailing Address - Fax:803-256-3932
Practice Address - Street 1:9 MEDICAL PARK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6873
Practice Address - Country:US
Practice Address - Phone:803-254-4110
Practice Address - Fax:803-256-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC61358Medicare UPIN