Provider Demographics
NPI:1891966321
Name:SRIBNICK, MICHAEL GORDON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:SRIBNICK
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 1:2117 GERVAIS STREET
Mailing Address - Street 2:WAVERLY FAMILY PRACTICE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29403
Mailing Address - Country:US
Mailing Address - Phone:803-748-1181
Mailing Address - Fax:
Practice Address - Street 1:2117 GERVAIS STREET
Practice Address - Street 2:WAVERLY FAMILY PRATICE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-748-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7174207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB92133Medicare UPIN