Healthcare Provider Details

I. General information

NPI: 1386176865
Provider Name (Legal Business Name): MELISSA P.M. CISA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2097 HENRY TECKLENBURG DR STE 312W
CHARLESTON SC
29414-5744
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-1800
  • Fax:
Mailing address:
  • Phone: 843-789-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number85609
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: