Provider Demographics
NPI:1972777001
Name:PHYSIATRY AND REHABILITATION ASSOCIATES LLC
Entity Type:Organization
Organization Name:PHYSIATRY AND REHABILITATION ASSOCIATES LLC
Other - Org Name:COLUMBIA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:USAMA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GABR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-788-2225
Mailing Address - Street 1:113 BLARNEY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6244
Mailing Address - Country:US
Mailing Address - Phone:803-788-2225
Mailing Address - Fax:803-788-2120
Practice Address - Street 1:113 BLARNEY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6244
Practice Address - Country:US
Practice Address - Phone:803-788-2225
Practice Address - Fax:803-788-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28228207Q00000X, 208100000X
OH35084155208100000X, 208D00000X
MI4301102325208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4958Medicaid
SCGP4958Medicaid