Healthcare Provider Details

I. General information

NPI: 1467680249
Provider Name (Legal Business Name): LEONIDAS WALTHALL IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE MUSC - INTERNAL MEDICINE
CHARLESTON SC
29425-0100
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 Code208M00000X
TaxonomyHospitalist Physician
License Number31941
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL31941
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: