Healthcare Provider Details

I. General information

NPI: 1720652472
Provider Name (Legal Business Name): KARLY ANNE DERWITZ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRISMA HEALTH CHILDREN'S HOSPITAL OUTPATIENT CENTER 14 MEDICAL PARK, STE 400
COLUMBIA SC
29203
US

IV. Provider business mailing address

PRISMA HEALTH CHILDREN'S HOSPITAL OUTPATIENT CENTER 14 MEDICAL PARK, STE 400
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-6979
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL83483
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: