Healthcare Provider Details

I. General information

NPI: 1841369774
Provider Name (Legal Business Name): STACY RENEE CAUDILL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9298 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

IV. Provider business mailing address

9298 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-8277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL29043
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: