Healthcare Provider Details

I. General information

NPI: 1750492534
Provider Name (Legal Business Name): DALE RAYMOND TABOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST VA ANESTHESIA SERVICE
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

109 BEE ST VA ANESTHESIA SERVICE
CHARLESTON SC
29401-5703
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-7345
  • Fax:
Mailing address:
  • Phone: 843-789-7345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number21738
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: