Provider Demographics
NPI:1770809428
Name:SOUTHEASTERN EAR NOSE THROAT ALLERGY AND SLEEP DISORDERS INSTITUTE
Entity type:Organization
Organization Name:SOUTHEASTERN EAR NOSE THROAT ALLERGY AND SLEEP DISORDERS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUNNLAUGSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-509-7200
Mailing Address - Street 1:1040 PINNACLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5735
Mailing Address - Country:US
Mailing Address - Phone:803-509-7200
Mailing Address - Fax:803-509-7213
Practice Address - Street 1:1040 PINNACLE POINT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5735
Practice Address - Country:US
Practice Address - Phone:803-509-7200
Practice Address - Fax:803-509-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28760207YS0012X, 207YS0123X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5437Medicaid
SCDE5192OtherFEDERAL DEA
SC9612Medicare PIN
SCGP5437Medicaid