Basic Information
| Provider Information | |||||||||
| NPI: | 1942266507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATZ | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 OLD TROLLEY RD STE H | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294858928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432128080 | ||||||||
| FaxNumber: | 8432128077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19100 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080141029 | 01 | SC | MEDICARE RAIL ROAD | OTHER | 1487807871 | 01 | SC | SITE NPI# | OTHER | GP4992 | 01 | SD | MEDICAID GROUP# | OTHER | 191009 | 05 | SC | MEDICAID |