Healthcare Provider Details

I. General information

NPI: 1013153576
Provider Name (Legal Business Name): JOHN MICHALE TAYLOR PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RICHLAND MEDICAL PARK DR
COLUMBIA SC
29203-6863
US

IV. Provider business mailing address

3555 HARDEN ST EXT. 15 MEDICAL PARK SUITE 300
COLUMBIA SC
29203-6894
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4807
  • Fax: 803-434-4838
Mailing address:
  • Phone: 803-434-6411
  • Fax: 803-434-1537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number504
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: