Healthcare Provider Details

I. General information

NPI: 1487067476
Provider Name (Legal Business Name): KATHERINE MARIE MATTHIAS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N A ST
EASLEY SC
29640-2144
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-855-0001
  • Fax: 864-855-5030
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36690
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier366990
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
IdentifierSCB281
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: