Basic Information
Provider Information | |||||||||
NPI: | 1740605864 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PIEDMONT PODIATRY ASSOC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8141 ROURK STREET | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 29572 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032851411 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 700 NORTH A STREET | ||||||||
Address2: |   | ||||||||
City: | EASLEY | ||||||||
State: | SC | ||||||||
PostalCode: | 29640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642323668 | ||||||||
FaxNumber: | 8642710526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2014 | ||||||||
LastUpdateDate: | 06/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PERCIVAL | ||||||||
AuthorizedOfficialFirstName: | BRANDON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8032851411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.P.M. | ||||||||
NPICertificationDate: |   |
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.