Provider Demographics
NPI:1750448189
Name:IMBEAU, STEPHEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:IMBEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CHEVES ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506
Mailing Address - Country:US
Mailing Address - Phone:843-679-9335
Mailing Address - Fax:843-669-4214
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:SUITE 420
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506
Practice Address - Country:US
Practice Address - Phone:843-679-9335
Practice Address - Fax:843-669-4214
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9690207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC096906Medicaid
B92668Medicare UPIN