MEDICARE: OBSTETRICS & GYNECOLOGICAL ASSOCIATES, PA

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	207VG0400X	Gynecology Physician	4891	SC

General Provider Information

NPI Number	:	1669470357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OBSTETRICS & GYNECOLOGICAL ASSOCIATES, PA

Provider Business Mailing Address
First Line	:	853 N CHURCH ST
Second Line	:	STE 400
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3098
Country	:	US
Telephone Number	:	864-582-4567
Fax Number	:	864-582-5397

Provider Business Practice Location Address
First Line	:	853 N CHURCH ST
Second Line	:	STE 400
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3098
Country	:	US
Telephone Number	:	864-582-4567
Fax Number	:	864-582-5397

Authorized Official
Title or Position	:	MD
Name	:	J SIDNEY FULMER
Credential	:	MD
Telephone Number	:	864-582-4567

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	08/22/2020

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