Provider Demographics
NPI:1275578833
Name:ILLANGAKOON, SABI
Entity Type:Individual
Prefix:
First Name:SABI
Middle Name:
Last Name:ILLANGAKOON
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 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:
Practice Address - Street 1:2015 MARION ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2113
Practice Address - Country:US
Practice Address - Phone:803-898-0123
Practice Address - Fax:803-898-4892
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC216192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC216199Medicaid
SC327877Medicaid
SC216199Medicaid
SCH307293361Medicare PIN
SCH30729Medicare UPIN