Healthcare Provider Details

I. General information

NPI: 1174584916
Provider Name (Legal Business Name): JAMES GILDER BOUKNIGHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 HARDEN STREET EXT 15 MEDICAL PARK RD., SUITE 141
COLUMBIA SC
29203-6894
US

IV. Provider business mailing address

3555 HARDEN STREET EXT 15 MEDICAL PARK RD., SUITE 300
COLUMBIA SC
29203-6894
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4300
  • Fax: 803-434-4277
Mailing address:
  • Phone: 803-434-4300
  • Fax: 803-434-4277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14983
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number14983
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: