Provider Demographics
NPI:1699724849
Name:ETAS CLINIC, P.C.
Entity type:Organization
Organization Name:ETAS CLINIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EKONG
Authorized Official - Middle Name:I
Authorized Official - Last Name:ETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-226-5260
Mailing Address - Street 1:400 N FANT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5720
Mailing Address - Country:US
Mailing Address - Phone:864-226-5260
Mailing Address - Fax:864-226-5863
Practice Address - Street 1:400 N FANT ST
Practice Address - Street 2:SUITE A
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5720
Practice Address - Country:US
Practice Address - Phone:864-226-5260
Practice Address - Fax:864-226-5863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ETAS CLINIC, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-07
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC215011Medicaid
SCGP2896Medicaid
SCGP2896Medicaid
SCG564540281Medicare PIN