Healthcare Provider Details

I. General information

NPI: 1457573313
Provider Name (Legal Business Name): ALICIA RENEE PRIVETTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-8908
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 TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA115704
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA115704
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberA115704
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number36036
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: