Basic Information
| Provider Information | |||||||||
| NPI: | 1245715796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCMMA SC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631797 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452631797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457022711 | ||||||||
| FaxNumber: | 8882206560 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037749000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCURLOCK | ||||||||
| AuthorizedOfficialFirstName: | COREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9145232189 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.