Basic Information
| Provider Information | |||||||||
| NPI: | 1477590594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSSE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | AGAPE SENIOR PRIMARY CARE INC | ||||||||
| Address2: | 1053 CENTER STREET | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291696749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037262350 | ||||||||
| FaxNumber: | 8037539102 | ||||||||
| Practice Location | |||||||||
| Address1: | AGAPE SENIOR PRIMARY CARE INC DBA SC HOUSE CALLS | ||||||||
| Address2: | 1400 MAIN STREET | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434880101 | ||||||||
| FaxNumber: | 8434883130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15009 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | LL0292 | 05 | SC | MEDICAID |