Healthcare Provider Details

I. General information

NPI: 1356546170
Provider Name (Legal Business Name): WEST ASHLEY OBGYN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1843 ASHLEY RIVER RD
CHARLESTON SC
29407-4740
US

IV. Provider business mailing address

1843 ASHLEY RIVER RD
CHARLESTON SC
29407-4740
US

V. Phone/Fax

Practice location:
  • Phone: 843-769-4424
  • Fax: 843-769-4425
Mailing address:
  • Phone: 843-769-4424
  • Fax: 843-769-4425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14683
License Number StateSC

VIII. Authorized Official

Name: MRS. AGNES OYIBOKJA MUGHELLI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 843-769-4424