Provider Demographics
NPI:1508958216
Name:APEXCARE PA
Entity Type:Organization
Organization Name:APEXCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAJIDE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALOGUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-408-0225
Mailing Address - Street 1:1165 HIGHWAY 1 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-8966
Mailing Address - Country:US
Mailing Address - Phone:803-408-0225
Mailing Address - Fax:803-408-0729
Practice Address - Street 1:1165 HIGHWAY 1 S
Practice Address - Street 2:SUITE 200
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8966
Practice Address - Country:US
Practice Address - Phone:803-408-0225
Practice Address - Fax:803-408-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20381207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC203817Medicaid
SC8611Medicare PIN