Provider Demographics
NPI:1528037850
Name:SUMTER OBGYN PA
Entity Type:Organization
Organization Name:SUMTER OBGYN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/INS/BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCURRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-775-8351
Mailing Address - Street 1:PO BOX 1469
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-1469
Mailing Address - Country:US
Mailing Address - Phone:803-775-8351
Mailing Address - Fax:803-773-2635
Practice Address - Street 1:115 N SUMTER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4972
Practice Address - Country:US
Practice Address - Phone:803-775-8351
Practice Address - Fax:803-773-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA1346Medicaid
SCPA1346Medicaid