Basic Information
| Provider Information | |||||||||
| NPI: | 1255381083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 255 E BAY ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294012632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438533474 | ||||||||
| FaxNumber: | 8438533500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOWERY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | BW | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8438533474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207XX0801X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | GP0535 | 05 | SC | MEDICAID | GP9930 | 05 | SC | MEDICAID |