Basic Information
| Provider Information | |||||||||
| NPI: | 1225455835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8141 ROURK ST | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032851411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8020 MYRTLE TRACE DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432349100 | ||||||||
| FaxNumber: | 8432349103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2014 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | PERCIVAL | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8032851411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213E00000X | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.