Provider Demographics
NPI:1952940223
Name:INTERNAL MEDICINE SPECIALIST GROUP LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE SPECIALIST GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEOVYAAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-416-3710
Mailing Address - Street 1:225 S HERLONG AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2168
Mailing Address - Country:US
Mailing Address - Phone:803-366-3900
Mailing Address - Fax:803-366-1213
Practice Address - Street 1:225 S HERLONG AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2168
Practice Address - Country:US
Practice Address - Phone:803-366-3900
Practice Address - Fax:803-366-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT79073Medicaid