Basic Information
| Provider Information | |||||||||
| NPI: | 1699832089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLESTON SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DOUGHTY ST | ||||||||
| Address2: | SUITE 660 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435777550 | ||||||||
| FaxNumber: | 8438535588 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 DOUGHTY ST | ||||||||
| Address2: | SUITE 660 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435777550 | ||||||||
| FaxNumber: | 8438535588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE FACILITATOR | ||||||||
| AuthorizedOfficialTelephone: | 8435777550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PA7395 | 05 | SC | MEDICAID |