Healthcare Provider Details

I. General information

NPI: 1922323740
Provider Name (Legal Business Name): G T LITTLE MD P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RUTLEDGE AVE
CHARLESTON SC
29403-5352
US

IV. Provider business mailing address

280 RUTLEDGE AVE
CHARLESTON SC
29403-5352
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-6336
  • Fax: 843-722-6302
Mailing address:
  • Phone: 843-722-6336
  • Fax: 843-722-6302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number8051
License Number StateSC

VIII. Authorized Official

Name: DR. GENERAL THEOPHILUS LITTLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 843-722-6336