Provider Demographics
NPI:1699280644
Name:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Entity type:Organization
Organization Name:MIDLANDS NEUROLOGY & PAIN ASSOC, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELEANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBURU-OGBONNAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-788-0038
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:STATE PARK
Mailing Address - State:SC
Mailing Address - Zip Code:29147-0209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1218
Practice Address - Country:US
Practice Address - Phone:803-788-0038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC183232084A0401X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1403Medicaid