Basic Information
Provider Information | |||||||||
NPI: | 1154438075 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIBE513, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PARKSIDE OB-GYN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 525 VERDAE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296074021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642720388 | ||||||||
FaxNumber: | 8642139237 | ||||||||
Practice Location | |||||||||
Address1: | 525 VERDAE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296074021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642720388 | ||||||||
FaxNumber: | 8642139237 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 03/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OOSTDYK | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COORDINATOR, PROVIDER RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 8642720388 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207VG0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 2080A0000X |   | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
ID | Type | State | Issuer | Description | GP4514 | 05 | SC |   | MEDICAID |