Healthcare Provider Details

I. General information

NPI: 1760427504
Provider Name (Legal Business Name): POLLY A WURTHMANN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 SAVAGE RD
CHARLESTON SC
29407-4726
US

IV. Provider business mailing address

PO BOX 1583
MT PLEASANT SC
29465-1583
US

V. Phone/Fax

Practice location:
  • Phone: 843-576-2588
  • Fax: 843-576-2610
Mailing address:
  • Phone: 843-343-3740
  • Fax: 843-375-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number18657
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number18657
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: