Healthcare Provider Details

I. General information

NPI: 1578523890
Provider Name (Legal Business Name): CARROLL H FOWLKES III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BEAUFORT MEMORIAL EXPRESS CARE & OCCUPATIONAL HEALTH 1 BURNT CHURCH RD, STE A
BLUFFTON SC
29910-6405
US

IV. Provider business mailing address

955 RIBAUT RD BMAC CREDENTIALING
BEAUFORT SC
29902-5441
US

V. Phone/Fax

Practice location:
  • Phone: 843-706-2185
  • Fax: 855-299-5693
Mailing address:
  • Phone: 843-522-7843
  • Fax: 843-522-5678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102049892
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36208
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: