Provider Demographics
NPI:1144516386
Name:PANCHOLI, SUCHITA SHIRISH (MD)
Entity type:Individual
Prefix:
First Name:SUCHITA
Middle Name:SHIRISH
Last Name:PANCHOLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2 MEDICAL PARK RD STE 203
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-545-5444
Practice Address - Fax:803-933-3042
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00900207R00000X
SC61210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1144516386Medicaid
SC612108Medicaid
NC18652OtherBCBS NC