Provider Demographics
NPI:1134153083
Name:SOUTH CAROLINA ENT ALLERGY & SLEEP MEDICINE PA
Entity type:Organization
Organization Name:SOUTH CAROLINA ENT ALLERGY & SLEEP MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-424-2207
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-0520
Mailing Address - Country:US
Mailing Address - Phone:803-408-3277
Mailing Address - Fax:803-408-3277
Practice Address - Street 1:15 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9198
Practice Address - Country:US
Practice Address - Phone:803-408-3277
Practice Address - Fax:803-408-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE5192OtherUNSPECIFIED
SCGP4316Medicaid