Provider Demographics
NPI:1952682981
Name:IRMO MEDICAL GROUP
Entity Type:Organization
Organization Name:IRMO MEDICAL GROUP
Other - Org Name:ADVANTAGE HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-610-8206
Mailing Address - Street 1:120 VAN DER HORST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 VAN DER HORST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7595
Practice Address - Country:US
Practice Address - Phone:843-610-8206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty