UNIVERSITY MEDICAL GROUP DEPARTMENT OF OBGYN (DIVISION OF REPRODUCTIVE ENDOCRINOLOGY & INFERTILITY) - NPI NUMBER 1710944749

Summary

Provider Name: UNIVERSITY MEDICAL GROUP DEPARTMENT OF OBGYN (DIVISION OF REPRODUCTIVE ENDOCRINOLOGY & INFERTILITY)

NPI Number: 1710944749

Clasification: Clinic/Center (261QM1300X)

Specialization: Multi-Specialty

Address:
890 W FARIS RD
SUITE 470
GREENVILLE, SC
ZIP 29605

Phone Number: (864) 455-1600



Detailed Information

UNIVERSITY MEDICAL GROUP DEPARTMENT OF OBGYN is a multi-specialty clinic/center in Greenville, SC. The assigned NPI number for this provider is 1710944749 and is registered as an organization entity type.
The provider Is Doing Business As Division Of Reproductive Endocrinology & Infertility.

The provider's business address is:

890 W FARIS RD
SUITE 470
GREENVILLE, SC
ZIP 29605-247
Phone: (864) 455-1600
Fax: (864) 455-3095

The provider's authorized official is Paul Bruce Miller .
The authorized official title is Staff Physician and has the following contact phone number (864) 455-1600.

The enumeration date for this NPI number is 4/26/2006 and was last updated on 7/9/2007.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 261QM1300X Clinic/Center Multi-Specialty 19348 SC Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 193481 MEDICAID SC
2 G61701 MEDICARE UPIN SC

NPI Record

No. Field Name Field Value
1 NPI 1710944749
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name UNIVERSITY MEDICAL GROUP DEPARTMENT OF OBGYN
5 Provider Other Organization Name DIVISION OF REPRODUCTIVE ENDOCRINOLOGY & INFERTILITY
6 Provider Other Organization Name Type Code 3
7 Provider First Line Business Practice Location Address 890 W FARIS RD
8 Provider Second Line Business Practice Location Address SUITE 470
9 Provider Business Practice Location Address City Name GREENVILLE
10 Provider Business Practice Location Address State Name SC
11 Provider Business Practice Location Address Postal Code 296054247
12 Provider Business Practice Location Address Country Code If outside U S US
13 Provider Business Practice Location Address Telephone Number 8644551600
14 Provider Business Practice Location Address Fax Number 8644553095
15 Provider Enumeration Date 4/26/2006
16 Last Update Date 7/9/2007
17 Authorized Official Last Name MILLER
18 Authorized Official First Name PAUL
19 Authorized Official Middle Name BRUCE
20 Authorized Official Title or Position STAFF PHYSICIAN
21 Authorized Official Telephone Number 8644551600
22 Healthcare Provider Taxonomy Code 1 261QM1300X
23 Provider License Number 1 19348
24 Provider License Number State Code 1 SC
25 Healthcare Provider Primary Taxonomy Switch 1 Y
26 Other Provider Identifier 1 193481
27 Other Provider Identifier Type Code 1 05
28 Other Provider Identifier State 1 SC
29 Other Provider Identifier 2 G61701
30 Other Provider Identifier Type Code 2 02
31 Other Provider Identifier State 2 SC
32 Authorized Official Name Prefix Text DR.
33 Authorized Official Credential Text MD

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This page was last updated on: 8/12/2014
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