Healthcare Provider Details

I. General information

NPI: 1225455835
Provider Name (Legal Business Name): SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 MYRTLE TRACE DR
CONWAY SC
29526-8945
US

IV. Provider business mailing address

8141 ROURK ST
MYRTLE BEACH SC
29572-4128
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-9100
  • Fax: 843-234-9103
Mailing address:
  • Phone: 803-285-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateSC

VIII. Authorized Official

Name: BRANDON S PERCIVAL
Title or Position: PRESIDENT
Credential:
Phone: 803-285-1411