Healthcare Provider Details

I. General information

NPI: 1710240486
Provider Name (Legal Business Name): PETER B COOLIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E GREENVILLE ST SUITE 3700
ANDERSON SC
29621-1580
US

IV. Provider business mailing address

2000 E GREENVILLE ST SUITE 3700
ANDERSON SC
29621-1580
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-1475
  • Fax: 864-512-1930
Mailing address:
  • Phone: 864-512-1475
  • Fax: 864-512-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34956
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: