Provider Demographics
NPI:1124096979
Name:MIDLANDS ORTHOPAEDICS AND NEUROSURGERY, PA
Entity type:Organization
Organization Name:MIDLANDS ORTHOPAEDICS AND NEUROSURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:KIMBERLY
Authorized Official - Last Name:SOOTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-256-4107
Mailing Address - Street 1:1910 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3520
Mailing Address - Country:US
Mailing Address - Phone:803-256-4107
Mailing Address - Fax:803-253-6676
Practice Address - Street 1:1013 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2824
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:803-253-6676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X, 2081P2900X, 207X00000X
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME633OtherMEDICAID DME
SCPA3335Medicaid
SC0266040004Medicare NSC
SC2121Medicare PIN