Healthcare Provider Details

I. General information

NPI: 1699334417
Provider Name (Legal Business Name): CARTER JOHN DEGENNARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RICHLAND MEDICAL PARK DR STE 350
COLUMBIA SC
29203-6896
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 34-341-6638
  • Fax: 803-434-3946
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number82737
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: