Provider Demographics
NPI:1225382336
Name:DIOMAMPO, SHERILYN BERMUDEZ
Entity Type:Individual
Prefix:
First Name:SHERILYN
Middle Name:BERMUDEZ
Last Name:DIOMAMPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100147
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3147
Mailing Address - Country:US
Mailing Address - Phone:864-512-4590
Mailing Address - Fax:864-512-4595
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:SUITE 5130
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1580
Practice Address - Country:US
Practice Address - Phone:864-512-4590
Practice Address - Fax:864-512-4595
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40092207RR0500X
OH57.020115207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400925Medicaid
SCSC93357111Medicare PIN