Provider Demographics
NPI:1205010188
Name:MIDLANDS NEPHROLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:MIDLANDS NEPHROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-736-0963
Mailing Address - Street 1:204 COWDRAY PARK
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-8128
Mailing Address - Country:US
Mailing Address - Phone:803-736-0963
Mailing Address - Fax:803-736-0963
Practice Address - Street 1:204 COWDRAY PARK
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-8128
Practice Address - Country:US
Practice Address - Phone:803-736-0963
Practice Address - Fax:803-736-0963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10735174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP 1717Medicaid
SCGP 1717Medicaid
C614225354Medicare PIN