Basic Information
| Provider Information | |||||||||
| NPI: | 1679782205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDLANDS PSYCHIATRIC SERVICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 ALPINE CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292236385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793548 | ||||||||
| FaxNumber: | 8037797055 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 ALPINE CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292236385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793548 | ||||||||
| FaxNumber: | 8037797055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOZINGO | ||||||||
| AuthorizedOfficialFirstName: | ELLIE | ||||||||
| AuthorizedOfficialMiddleName: | BRYAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8037793548 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TP0016X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 104100000X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.