Provider Demographics
NPI:1689136475
Name:IPAYE-ADEBIYI, PRUDENCE NASSEM (MD)
Entity type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:NASSEM
Last Name:IPAYE-ADEBIYI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6834
Practice Address - Country:US
Practice Address - Phone:803-434-6095
Practice Address - Fax:803-758-0120
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90102207P00000X, 207Q00000X, 207QH0002X
OK39801207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine