Healthcare Provider Details

I. General information

NPI: 1639240765
Provider Name (Legal Business Name): LATASHA BURGESS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CHEVES ST STE 400
FLORENCE SC
29506-2649
US

IV. Provider business mailing address

800 E CHEVES ST STE 400
FLORENCE SC
29506-2649
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-7341
  • Fax: 843-777-7345
Mailing address:
  • Phone: 843-777-7341
  • Fax: 843-777-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number92875
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049877
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: