Basic Information
| Provider Information | |||||||||
| NPI: | 1316912066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOZINGO | ||||||||
| FirstName: | ELLIE | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 125 ALPINE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793548 | ||||||||
| FaxNumber: | 8037797055 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 ALPINE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793548 | ||||||||
| FaxNumber: | 8037797055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 15050 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 582296052001 | 01 | BCBS PALMETTO HEALTH | OTHER | 150507 | 05 | SC | MEDICAID | 400186 | 05 | SC | MEDICAID |