Healthcare Provider Details

I. General information

NPI: 1578531919
Provider Name (Legal Business Name): ALICIA RUTH SANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SINGLETON RIDGE RD
CONWAY SC
29526-9154
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTENTION PATIENT ACCOUNTING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7300
  • Fax: 843-347-8459
Mailing address:
  • Phone: 843-234-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number87204
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number87204
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number87204
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number0101263595
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: