Healthcare Provider Details

I. General information

NPI: 1699832089
Provider Name (Legal Business Name): CHARLESTON SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DOUGHTY ST SUITE 660
CHARLESTON SC
29403-5736
US

IV. Provider business mailing address

125 DOUGHTY ST SUITE 660
CHARLESTON SC
29403-5736
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-7550
  • Fax: 843-853-5588
Mailing address:
  • Phone: 843-577-7550
  • Fax: 843-853-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. STANLEY M. WILSON
Title or Position: PRACTICE FACILITATOR
Credential: M.D.
Phone: 843-577-7550