Basic Information
| Provider Information | |||||||||
| NPI: | 1710561949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EPC SC ACO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901A SPICEWOOD SPRINGS RD STE 201 | ||||||||
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| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7372266700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2375 BAKER HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294058233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7372266700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2021 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | GAMBOA | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7372266700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.