Healthcare Provider Details

I. General information

NPI: 1487696019
Provider Name (Legal Business Name): ROBERT SCOTT LAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2097 HENRY TECKLENBURG DR STE 201W
CHARLESTON SC
29414-5739
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-402-1211
  • Fax: 843-606-8088
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22236
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number22236
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: