Provider Demographics
NPI:1023677945
Name:HEALOGICS SPECIALTY PHYSICIANS OF SOUTH CAROLINA, LLC
Entity type:Organization
Organization Name:HEALOGICS SPECIALTY PHYSICIANS OF SOUTH CAROLINA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-446-3519
Mailing Address - Street 1:PO BOX 638509
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1630 SKYLYN DRIVE
Practice Address - Street 2:SUITE 420
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:904-446-3825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALOGICS SPECIALTY PHYSICIANS OF SOUTH CAROLINA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-13
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7200Medicaid