Basic Information
| Provider Information | |||||||||
| NPI: | 1588792030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA CTR FOR OCCUP HEALTH | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHARLESTON MEDICAL ARTS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 GOER DR | ||||||||
| Address2: | STE. 205 | ||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294066500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435541029 | ||||||||
| FaxNumber: | 8435541103 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 GOER DR | ||||||||
| Address2: | STE. 205 | ||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294066500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435541029 | ||||||||
| FaxNumber: | 8435541103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRAYTON | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8435541029 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 67825 | SC | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | GP0280 | 05 | SC | MEDICAID |