Provider Demographics
NPI:1558331264
Name:UNIVERSITY OF SOUTH CAROLINA SYSTEM
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH CAROLINA SYSTEM
Other - Org Name:MONTGOMERY SPEECH, LANGUAGE AND HEARING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-777-2630
Mailing Address - Street 1:1705 COLLEGE ST STE 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3917
Mailing Address - Country:US
Mailing Address - Phone:803-777-2614
Mailing Address - Fax:803-777-3081
Practice Address - Street 1:1705 COLLEGE STREET SUITE 220
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-3323
Practice Address - Country:US
Practice Address - Phone:803-777-2614
Practice Address - Fax:803-777-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC04049404S231H00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426521Medicaid
SC426521Medicaid
SC7729Medicare PIN