Provider Demographics
NPI:1528143922
Name:MIDLANDS ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:MIDLANDS ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:SUZETTE
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-749-3770
Mailing Address - Street 1:1 WELLNESS BLVD STE 111
Mailing Address - Street 2:MIDLANDS ENDOSCOPY CENTER, LLC
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2873
Mailing Address - Country:US
Mailing Address - Phone:803-749-3770
Mailing Address - Fax:803-749-3558
Practice Address - Street 1:1 WELLNESS BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-749-3770
Practice Address - Fax:803-749-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCASC059Medicaid
SCASC059Medicaid
Y31402Medicare UPIN