Healthcare Provider Details

I. General information

NPI: 1376651943
Provider Name (Legal Business Name): RICHARD D SHROUDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CLEMSON RD
COLUMBIA SC
29229-4341
US

IV. Provider business mailing address

300 RICE MEADOW WAY STE B
COLUMBIA SC
29229-8424
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-6146
  • Fax: 803-462-0312
Mailing address:
  • Phone: 803-788-6360
  • Fax: 803-462-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23441
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: