Healthcare Provider Details

I. General information

NPI: 1043213622
Provider Name (Legal Business Name): CHARLES A. KOLB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W GREENWOOD ST SUITE 9
ABBEVILLE SC
29620-5678
US

IV. Provider business mailing address

PO BOX 968
ABBEVILLE SC
29620-0968
US

V. Phone/Fax

Practice location:
  • Phone: 864-366-9681
  • Fax: 864-366-5600
Mailing address:
  • Phone: 864-366-9681
  • Fax: 864-366-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11866
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: