Healthcare Provider Details

I. General information

NPI: 1104899574
Provider Name (Legal Business Name): DR. FULLER MCIVER PRICKETT III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 TAYLOR ST
COLUMBIA SC
29201-2915
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5137
  • Fax: 803-296-5499
Mailing address:
  • Phone: 803-434-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number19571
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: