| |
4605 Monticello Rd Bldgb, Ste.2 Columbia SC 29203-4156 | |
(803) 753-5590 | |
(803) 753-5592 |
Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 4605 Monticello Rd, Columbia, South Carolina |
Authorized Official Name and Position | Stuart A Hamilton (CEO) |
Authorized Official Contact | 8037335969 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
Po Box 3788 Columbia SC 29230-3788 Ph: (803) 733-5969 | 4605 Monticello Rd Bldgb, Ste.2 Columbia SC 29203-4156 Ph: (803) 753-5590 |
NPI Number | 1467795815 |
---|---|
Provider Enumeration Date | 04/04/2013 |
Last Update Date | 02/03/2022 |
Medicare PECOS PAC ID | 3274434220 |
---|---|
Medicare Enrollment ID | O20131014000882 |
Identifier | Type | State | Issuer |
---|---|---|---|
1467795815 | NPI | - | NPPES |
FQC179 | Medicaid | SC | |
FQC031 | Medicaid | SC | |
CBP018 | Medicaid | SC |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
Northlake Family Medical Practice Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 3000 Ne Medical Park, Ste 101, Columbia, SC 29223 Phone: 803-419-5131 Fax: 803-419-5130 | |
Lagniappe Medical Clinics, Llc Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 74 Polo Rd, Columbia, SC 29223 Phone: 803-419-7780 Fax: 803-419-7781 | |