Healthcare Provider Details

I. General information

NPI: 1699960054
Provider Name (Legal Business Name): DOMENIC J DEMICHELE,MD,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S CASHUA DR SUITE A
FLORENCE SC
29501-4001
US

IV. Provider business mailing address

125 A CASHUA DR
FLORENCE SC
29501
US

V. Phone/Fax

Practice location:
  • Phone: 843-669-1615
  • Fax: 843-669-1613
Mailing address:
  • Phone: 843-669-1615
  • Fax: 843-669-1613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number15062
License Number StateSC

VIII. Authorized Official

Name: DR. DOMENIC J DEMICHELE
Title or Position: OWNER
Credential: M.D., PH.D.
Phone: 843-669-1615