Healthcare Provider Details

I. General information

NPI: 1760800650
Provider Name (Legal Business Name): CARMINE SUPPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-3816
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number83194
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: