Healthcare Provider Details

I. General information

NPI: 1053376988
Provider Name (Legal Business Name): BARRETT C SHILO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 LAUREL ST
COLUMBIA SC
29204-1018
US

IV. Provider business mailing address

2001 LAUREL ST
COLUMBIA SC
29204-1018
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-3278
  • Fax: 803-255-2715
Mailing address:
  • Phone: 803-254-3278
  • Fax: 803-255-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA000162L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: