Healthcare Provider Details

I. General information

NPI: 1669009908
Provider Name (Legal Business Name): GHASSAN JAMAL WADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-1344
  • Fax: 843-876-1344
Mailing address:
  • Phone: 865-305-9410
  • Fax: 865-305-8261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number97397
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: