Provider Demographics
NPI:1134219223
Name:SOUTH CAROLINA NEPHROLOGY AND HYPERTENSION
Entity type:Organization
Organization Name:SOUTH CAROLINA NEPHROLOGY AND HYPERTENSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUSTAFA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-531-2220
Mailing Address - Street 1:PO BOX 2981
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-2981
Mailing Address - Country:US
Mailing Address - Phone:803-531-2220
Mailing Address - Fax:803-531-7975
Practice Address - Street 1:3709 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1403
Practice Address - Country:US
Practice Address - Phone:803-531-2220
Practice Address - Fax:803-531-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17881207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3383Medicaid
SCGP3383Medicaid
SC=========OtherTAX ID