Basic Information
| Provider Information | |||||||||
| NPI: | 1184828808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLESTON BONE & JOINT PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 E BAY ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294012632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438533474 | ||||||||
| FaxNumber: | 8438533500 | ||||||||
| Practice Location | |||||||||
| Address1: | 767 JOHNNIE DODDS BLVD | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438533474 | ||||||||
| FaxNumber: | 8438533500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THESING | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8438533474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 213E00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | GP0535 | 05 | SC | MEDICAID |