Healthcare Provider Details

I. General information

NPI: 1376518795
Provider Name (Legal Business Name): EDWIN LEO BLITCH IV DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9313 MEDICAL PLAZA DR 301
CHARLESTON SC
29406-9155
US

IV. Provider business mailing address

9313 MEDICAL PLAZA DR 301
CHARLESTON SC
29406-9155
US

V. Phone/Fax

Practice location:
  • Phone: 843-553-2909
  • Fax: 843-553-4684
Mailing address:
  • Phone: 843-553-2909
  • Fax: 843-553-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number134
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: