Provider Demographics
NPI:1174506497
Name:COLUMBIA MEDICAL GROUP
Entity Type:Organization
Organization Name:COLUMBIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-790-4700
Mailing Address - Street 1:4540 TRENHOLM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-4462
Mailing Address - Country:US
Mailing Address - Phone:803-790-4700
Mailing Address - Fax:803-790-6130
Practice Address - Street 1:4540 TRENHOLM RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-4462
Practice Address - Country:US
Practice Address - Phone:803-790-4700
Practice Address - Fax:803-790-6130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14628207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2807Medicaid
SCD17897Medicare UPIN
SCB91630Medicare UPIN
SC6742Medicare UPIN
SCC60872Medicare UPIN
SCG04724Medicare UPIN
SCGP2807Medicaid
SCG78207Medicare UPIN
SCE12474Medicare UPIN