Healthcare Provider Details

I. General information

NPI: 1124099874
Provider Name (Legal Business Name): HOLBROOK WYMAN RAYNAL M.D., D.H.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S BROAD ST
CLINTON SC
29325-2505
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-0973
  • Fax: 864-833-9571
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8942
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: