Healthcare Provider Details

I. General information

NPI: 1477963676
Provider Name (Legal Business Name): ANTHONY MICHAEL DOMINICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SABIN ST
CHARLESTON SC
29425-8918
US

IV. Provider business mailing address

39 SABIN ST
CHARLESTON SC
29425-8918
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-2813
  • Fax: 843-792-0644
Mailing address:
  • Phone: 843-876-2813
  • Fax: 843-792-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number92498
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: