Provider Demographics
NPI:1215969696
Name:UNIVERSITY SPECIALTY CLINIC
Entity type:Organization
Organization Name:UNIVERSITY SPECIALTY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:803-434-6116
Mailing Address - Street 1:15 MEDICAL PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6843
Mailing Address - Country:US
Mailing Address - Phone:803-545-5022
Mailing Address - Fax:803-256-0977
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6116
Practice Address - Fax:803-434-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2223Medicaid
SC2353Medicare PIN