Basic Information
| Provider Information | |||||||||
| NPI: | 1598768830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISTEFANO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777092 | ||||||||
| FaxNumber: | 8437777102 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 CHESTERFIELD HWY | ||||||||
| Address2: | |||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295207001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435730010 | ||||||||
| FaxNumber: | 8435370009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 119582 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 51607 | SC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 516070 | 05 | SC | MEDICAID |