Basic Information
| Provider Information | |||||||||
| NPI: | 1376868034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALBANO | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | WALTER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976328 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 877 W FARIS RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976328 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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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 | 207QS0010X | 37729 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 25MB09504600 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | OS017133 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 37729 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 377292 | 05 | SC | MEDICAID |