Basic Information
| Provider Information | |||||||||
| NPI: | 1255306965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIEL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034542613 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 RIBAUT ROAD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435225087 | ||||||||
| FaxNumber: | 8435225007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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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 | 207L00000X | 16807 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 16807 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | 16807 | SC | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 168071 | 05 | SC | MEDICAID |