Provider Demographics
NPI:1861520157
Name:SUMTER PODIATRY SERVICES PA
Entity type:Organization
Organization Name:SUMTER PODIATRY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-469-9255
Mailing Address - Street 1:PO BOX 1485
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-1485
Mailing Address - Country:US
Mailing Address - Phone:803-469-9255
Mailing Address - Fax:803-469-9253
Practice Address - Street 1:2620 HARDEE CV
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1893
Practice Address - Country:US
Practice Address - Phone:803-469-9255
Practice Address - Fax:803-469-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPDO886213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9925Medicaid
SCU315188022Medicare UPIN