Healthcare Provider Details

I. General information

NPI: 1730354259
Provider Name (Legal Business Name): CAROLINA CENTER FOR FERTILITY & ENDOCRINOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 BLANDING ST SUITE 205
COLUMBIA SC
29201-2967
US

IV. Provider business mailing address

1410 BLANDING ST SUITE 205
COLUMBIA SC
29201-2967
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-6320
  • Fax: 803-779-6323
Mailing address:
  • Phone: 803-779-6320
  • Fax: 803-779-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number10002
License Number StateSC

VIII. Authorized Official

Name: DR. EDWARD E. MOORE
Title or Position: OWNER
Credential: M.D.
Phone: 803-779-6320