Provider Demographics
NPI:1447229141
Name:BANGCO, MARIO S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:S
Last Name:BANGCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PATIENT ACCOUNTING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6827
Mailing Address - Fax:843-234-6990
Practice Address - Street 1:8024 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-234-8950
Practice Address - Fax:843-234-8951
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC170952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC130013055OtherRAILROAD MEDICARE
NC7906457OtherINDIVIDUAL
SC170950Medicaid
NC7906457OtherINDIVIDUAL
SC571035884OtherTAX ID
SC170950Medicaid