Healthcare Provider Details

I. General information

NPI: 1972584712
Provider Name (Legal Business Name): CHARLES A BICKERSTAFF JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WAPPOO CREEK DR STE 10C
CHARLESTON SC
29412
US

IV. Provider business mailing address

452 FOLLY RD SUITE A
CHARLESTON SC
29412-2641
US

V. Phone/Fax

Practice location:
  • Phone: 843-762-9321
  • Fax: 843-406-9777
Mailing address:
  • Phone: 843-762-9321
  • Fax: 843-406-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number8659
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: