Provider Demographics
NPI:1629084132
Name:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Entity Type:Organization
Organization Name:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:E
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBURU-OGBONNAYA MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-788-0038
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Mailing Address - City:STATE PARK
Mailing Address - State:SC
Mailing Address - Zip Code:29147-0209
Mailing Address - Country:US
Mailing Address - Phone:803-788-0038
Mailing Address - Fax:803-788-0655
Practice Address - Street 1:2601 MILLWOOD AVE
Practice Address - Street 2:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1218
Practice Address - Country:US
Practice Address - Phone:803-788-0038
Practice Address - Fax:803-788-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC183232084N0400X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1403Medicaid
SCGP1403Medicaid
SC5070Medicare PIN