Basic Information
| Provider Information | |||||||||
| NPI: | 1851424816 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA PODIATRY GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 325 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297210325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032851411 | ||||||||
| FaxNumber: | 8032839920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | BLDG 3 SUITE C | ||||||||
| City: | CHESTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297069769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003361279 | ||||||||
| FaxNumber: | 8032839920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | PERCIVAL | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 8032851411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | GP9953 | 05 | SC | MEDICAID | PD5364 | 05 | SC | MEDICAID | PD5408 | 05 | SC | MEDICAID |