Provider Demographics
NPI:1124070826
Name:SUMTER SURGICAL ASSOCIATE
Entity type:Organization
Organization Name:SUMTER SURGICAL ASSOCIATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-778-0212
Mailing Address - Street 1:115 N SUMTER ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4972
Mailing Address - Country:US
Mailing Address - Phone:803-778-0212
Mailing Address - Fax:803-775-7258
Practice Address - Street 1:115 N SUMTER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4972
Practice Address - Country:US
Practice Address - Phone:803-778-0212
Practice Address - Fax:803-775-7258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1090Medicaid
SCGP1090Medicaid