Basic Information
| Provider Information | |||||||||
| NPI: | 1093323875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA NEUROLOGY & NEUROIMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 SHIRE DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296213675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647162600 | ||||||||
| FaxNumber: | 8647162666 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 SHIRE DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296213675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647162600 | ||||||||
| FaxNumber: | 8647162666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2020 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | KUMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8647162600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 34121 | 01 | SC | STATE LICENSE | OTHER |