Healthcare Provider Details

I. General information

NPI: 1841483344
Provider Name (Legal Business Name): CHARLES KENNETH EDSALL I M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 11/23/2022
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEALTHY WAY STE 1200
ANDERSON SC
29621
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-6140
  • Fax: 864-512-6149
Mailing address:
  • Phone: 864-512-6140
  • Fax: 864-512-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29929
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number29929
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: