Provider Demographics
NPI:1801392634
Name:DOCTOR-GREENWADE, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:DOCTOR-GREENWADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23328
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-3328
Mailing Address - Country:US
Mailing Address - Phone:803-722-4988
Mailing Address - Fax:803-656-8135
Practice Address - Street 1:140 WILDEWOOD PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4312
Practice Address - Country:US
Practice Address - Phone:803-451-0449
Practice Address - Fax:803-753-9568
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC823005560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8160Medicaid