Basic Information
| Provider Information | |||||||||
| NPI: | 1578981452 | ||||||||
| 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: | 3700 SAWTELL RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295667873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433901333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | PERCIVAL | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8032851411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.