Provider Demographics
NPI:1417147059
Name:AMERIGROUP COMMUNITY CARE OF SOUTH CAROLI
Entity Type:Organization
Organization Name:AMERIGROUP COMMUNITY CARE OF SOUTH CAROLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT, REGULATORY S
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-962-6452
Mailing Address - Street 1:250 BERRYHILL ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6470
Mailing Address - Country:US
Mailing Address - Phone:803-551-2377
Mailing Address - Fax:
Practice Address - Street 1:250 BERRYHILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-6470
Practice Address - Country:US
Practice Address - Phone:803-551-2377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC161350302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCHM2400Medicaid