Healthcare Provider Details

I. General information

NPI: 1821094301
Provider Name (Legal Business Name): THEODORE G GOURDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 CHARLIE HALL BLVD
CHARLESTON SC
29414-5837
US

IV. Provider business mailing address

2001 2ND AVE STE 101
SUMMERVILLE SC
29486-7887
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-8000
  • Fax: 843-647-6066
Mailing address:
  • Phone: 843-793-5182
  • Fax: 843-266-5125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number13033
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number13033
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: