Healthcare Provider Details

I. General information

NPI: 1821025529
Provider Name (Legal Business Name): ANNA L BOUKNIGHT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 DEVINE ST STE 101
COLUMBIA SC
29205-2511
US

IV. Provider business mailing address

2801 DEVINE ST STE 101
COLUMBIA SC
29205-2511
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-7076
  • Fax: 803-256-0961
Mailing address:
  • Phone: 803-256-7076
  • Fax: 803-256-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number22059
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: