Provider Demographics
NPI:1407821721
Name:COLUMBIA NEPHROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:COLUMBIA NEPHROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-252-9907
Mailing Address - Street 1:121 PARK CENTRAL DR
Mailing Address - Street 2:200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6469
Mailing Address - Country:US
Mailing Address - Phone:803-252-9907
Mailing Address - Fax:803-252-9906
Practice Address - Street 1:121 PARK CENTRAL DR
Practice Address - Street 2:200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-252-9907
Practice Address - Fax:803-252-9906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA2773Medicaid
SC2040Medicare ID - Type Unspecified