Healthcare Provider Details

I. General information

NPI: 1720017346
Provider Name (Legal Business Name): JAMES R STALLWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK RD SUITE 400
COLUMBIA SC
29203-6877
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-255-3422
  • Fax: 803-255-3451
Mailing address:
  • Phone: 803-293-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9582
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: