Provider Demographics
NPI:1821009077
Name:SOUTH CAROLINA NEUROLOGICAL CLINIC PA
Entity type:Organization
Organization Name:SOUTH CAROLINA NEUROLOGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:803-254-6391
Mailing Address - Street 1:PO BOX 1488
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-1488
Mailing Address - Country:US
Mailing Address - Phone:803-254-6391
Mailing Address - Fax:803-799-0682
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 1-C
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-254-6391
Practice Address - Fax:803-799-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0421Medicaid
SCGP0421Medicaid