Basic Information
| Provider Information | |||||||||
| NPI: | 1861494502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENTZKY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | HAROLD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 340 MEDICAL PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296502441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647979400 | ||||||||
| FaxNumber: | 8647979402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 10427 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 104274 | 05 | SC | MEDICAID | 576007863006 | 01 | SC | BCBS | OTHER | P00615797 | 01 | SC | RAILROAD MEDICARE | OTHER | P00801272 | 01 | SC | RR MEDICARE | OTHER |