Provider Demographics
NPI:1831301761
Name:MIDLANDS GASTROENTEROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MIDLANDS GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEALVA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SUBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-786-0980
Mailing Address - Street 1:4100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-786-0980
Mailing Address - Fax:803-786-9132
Practice Address - Street 1:4100 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-786-0980
Practice Address - Fax:803-786-9132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153862Medicaid
SC099244Medicaid
SCGP3892Medicaid
SC099244Medicaid
SC153862Medicaid