Provider Demographics
NPI:1467406918
Name:SOUTH CAROLINA ONCOLOGY ASSOC PA
Entity Type:Organization
Organization Name:SOUTH CAROLINA ONCOLOGY ASSOC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUDRIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-461-3000
Mailing Address - Street 1:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171
Mailing Address - Country:US
Mailing Address - Phone:803-461-3000
Mailing Address - Fax:803-461-4917
Practice Address - Street 1:166 STONERIDGE DR
Practice Address - Street 2:SOUTH CAROLINA ONCOLOGY ASSOC
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210
Practice Address - Country:US
Practice Address - Phone:803-461-3000
Practice Address - Fax:803-461-4917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0971070001Medicare NSC
SC6275Medicare UPIN