Healthcare Provider Details

I. General information

NPI: 1649582032
Provider Name (Legal Business Name): MATILDA SERWAA MALM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 N FRASER ST
GEORGETOWN SC
29440-3260
US

IV. Provider business mailing address

P.O. BOX 608
MCCLELLANVILLE SC
29458-9405
US

V. Phone/Fax

Practice location:
  • Phone: 843-436-1333
  • Fax: 843-436-1335
Mailing address:
  • Phone: 843-887-3274
  • Fax: 843-887-3817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36708
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: