Provider Demographics
NPI:1891859757
Name:MIDLANDS GASTROENTEROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MIDLANDS GASTROENTEROLOGY ASSOCIATES
Other - Org Name:MIDLANDS GASTROENTEROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BURNETT
Authorized Official - Middle Name:WILLILAM
Authorized Official - Last Name:GALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-786-0980
Mailing Address - Street 1:4100 MAIN ST
Mailing Address - Street 2:SUITE 201
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:803-786-6452
Practice Address - Street 1:4100 MAIN ST
Practice Address - Street 2:SUITE 201
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:803-786-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9924174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3892Medicaid
SCGP3892Medicaid