Basic Information
| Provider Information | |||||||||
| NPI: | 1215269147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETHEL | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N FANT ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296215708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121417 | ||||||||
| FaxNumber: | 8645121823 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N FANT ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296215708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121340 | ||||||||
| FaxNumber: | 8645121749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 083407 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NPI # | 01 | SC | TRICARE (HUMANA) | OTHER | NPI/SSN | 01 | SC | BLUECROSS BLUESHIELD OF SC | OTHER | P00911158 | 01 | SC | RAILROAD MEDICARE | OTHER | AN2036 | 05 | SC | MEDICAID | NPI/SSN | 01 | SC | BLUECHOICE OF SC | OTHER | 20101737 | 01 | SC | SELECT HEALTH OF SC | OTHER |