Basic Information
| Provider Information | |||||||||
| NPI: | 1073596631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODINES | ||||||||
| FirstName: | RAMIRO | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2024 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292022024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Practice Location | |||||||||
| Address1: | 3655 MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295692827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437167000 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 16289 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 16289 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GP2672 | 05 | SC | MEDICAID | 162898 | 05 | SC | MEDICAID |