Provider Demographics
NPI:1437106788
Name:CAROLINA COLON & RECTAL
Entity Type:Organization
Organization Name:CAROLINA COLON & RECTAL
Other - Org Name:CCRS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-779-2005
Mailing Address - Street 1:1730 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2410
Mailing Address - Country:US
Mailing Address - Phone:803-779-2005
Mailing Address - Fax:803-765-0007
Practice Address - Street 1:1730 SAINT JULIAN PLACE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-779-2005
Practice Address - Fax:803-765-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC0691Medicaid
SCPC0691Medicaid