Healthcare Provider Details

I. General information

NPI: 1497289607
Provider Name (Legal Business Name): LAUREN FREDERIC VISSERMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN MICHELLE FREDERIC MD

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 07/08/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RUTLEDGE AVE FL 8
CHARLESTON SC
29425-6773
US

IV. Provider business mailing address

135 RUTLEDGE AVE FL 8
CHARLESTON SC
29425-8903
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-0888
  • Fax:
Mailing address:
  • Phone: 843-876-0888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020-02548
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberLL41118
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: