Healthcare Provider Details

I. General information

NPI: 1356307318
Provider Name (Legal Business Name): WILLIAM BLOUNT ELLISON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 SAINT ANDREWS BLVD
CHARLESTON SC
29407-7156
US

IV. Provider business mailing address

1033 SAINT ANDREWS BLVD
CHARLESTON SC
29407-7156
US

V. Phone/Fax

Practice location:
  • Phone: 843-723-6111
  • Fax: 843-723-0675
Mailing address:
  • Phone: 843-723-6111
  • Fax: 843-723-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number8245
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: