Provider Demographics
NPI:1174730485
Name:PRO SOMA, INC.
Entity type:Organization
Organization Name:PRO SOMA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:843-992-4627
Mailing Address - Street 1:PO BOX 7024
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-7024
Mailing Address - Country:US
Mailing Address - Phone:843-992-4627
Mailing Address - Fax:843-669-6116
Practice Address - Street 1:3330 EBENEZER CHASE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-8006
Practice Address - Country:US
Practice Address - Phone:843-992-4627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3617Medicaid
SCGP3617Medicaid