Basic Information
| Provider Information | |||||||||
| NPI: | 1407467038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEDDER | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1639 LAKE WATEREE DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295018153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434098506 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1005 E CHEVES ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777900 | ||||||||
| FaxNumber: | 8437777925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 24230 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP7151 | 05 | SC | MEDICAID |