Healthcare Provider Details

I. General information

NPI: 1548849482
Provider Name (Legal Business Name): MUSC AFFILIATE PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

PO BOX 936934
ATLANTA GA
31193-6934
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KARYN RAE
Title or Position: CHAIR, PAYOR RELATIONS & FINANCE
Credential:
Phone: 843-876-1344