MEDICARE: DR. PRISCILLA WILCOX HOLTZCLAW M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	24134	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00775520	OTHER	SC	RAILROAD MEDICARE ID - EFFECTIVE 5/11/2009

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164404844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRISCILLA WILCOX HOLTZCLAW M.D.

Provider Business Mailing Address
First Line	:	PO BOX 751649
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1649
Country	:	US
Telephone Number	:	843-789-1620
Fax Number	:	843-724-2440

Provider Business Practice Location Address
First Line	:	3400 SALTERBECK CT
Second Line	:	STE 100
City	:	MT PLEASANT
State	:	SC
Zip	:	29466-7118
Country	:	US
Telephone Number	:	843-971-3361
Fax Number	:	843-971-8492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	10/19/2015

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