Provider Demographics
NPI:1154438075
Name:TRIBE513, P.A.
Entity type:Organization
Organization Name:TRIBE513, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR, PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:OOSTDYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-272-0388
Mailing Address - Street 1:525 VERDAE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4021
Mailing Address - Country:US
Mailing Address - Phone:864-272-0388
Mailing Address - Fax:864-213-9237
Practice Address - Street 1:525 VERDAE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4021
Practice Address - Country:US
Practice Address - Phone:864-272-0388
Practice Address - Fax:864-213-9237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207R00000X, 2080A0000X, 2080A0000X
207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4514Medicaid