Basic Information
| Provider Information | |||||||||
| NPI: | 1255390993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTRAMED PLUS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | INTRAMED PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 112 SALUDA RIDGE CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037940200 | ||||||||
| FaxNumber: | 8037941302 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 SALUDA RIDGE CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037940200 | ||||||||
| FaxNumber: | 8037941302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THIELE | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8037940200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | 03224452600022043 | SC | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 8511179 | 01 | SC | AETNA INSURANCE PROVIDER | OTHER | 20016931 | 01 | SC | SELECT HEALTH PROVIDER # | OTHER | 726043 | 05 | SC | MEDICAID | DME296 | 05 | SC | MEDICAID | 4219792 | 01 | SC | NCPDP/NABP PROVIDER # | OTHER | 60-01522 | 01 | SC | CAROLINA CARE PLAN PROVID | OTHER |