Provider Demographics
NPI:1245715796
Name:CCMMA SC LLC
Entity type:Organization
Organization Name:CCMMA SC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCURLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-523-2189
Mailing Address - Street 1:PO BOX 631797
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1797
Mailing Address - Country:US
Mailing Address - Phone:845-702-2711
Mailing Address - Fax:888-220-6560
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-01
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty