Provider Demographics
NPI:1275561813
Name:INTERNAL MEDICINE AND CARDIOLOGY
Entity Type:Organization
Organization Name:INTERNAL MEDICINE AND CARDIOLOGY
Other - Org Name:PEACE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR / PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-233-2744
Mailing Address - Street 1:401 GUESS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4155
Mailing Address - Country:US
Mailing Address - Phone:864-233-2744
Mailing Address - Fax:864-233-7359
Practice Address - Street 1:401 GUESS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4155
Practice Address - Country:US
Practice Address - Phone:864-233-2744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2379Medicaid
SCGP2379Medicaid