Basic Information
| Provider Information | |||||||||
| NPI: | 1134187891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORSHAM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 FABER PLACE DR | ||||||||
| Address2: | |||||||||
| City: | N CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294058532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437474647 | ||||||||
| FaxNumber: | 8437470969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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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 | 208000000X | 14886 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 571020809045 | 01 | SC | TRICARE | OTHER | 571020809042 | 01 | SC | BCBS SC | OTHER | TL2170 | 05 | SC | MEDICAID |