Healthcare Provider Details

I. General information

NPI: 1063706992
Provider Name (Legal Business Name): KANNAN PUDUR SAMY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 JONATHAN LUCAS ST RM 409B
CHARLESTON SC
29425-8900
US

IV. Provider business mailing address

96 JONATHAN LUCAS ST RM 409B
CHARLESTON SC
29425-8900
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD93025
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD93025
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: