Healthcare Provider Details

I. General information

NPI: 1164961249
Provider Name (Legal Business Name): PPCP SPECIALTY PHYSICIANS , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110B SPRINGHALL DR
GOOSE CREEK SC
29445-5335
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 843-266-2520
  • Fax: 843-553-4436
Mailing address:
  • Phone: 843-695-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number39189
License Number StateSC

VIII. Authorized Official

Name: TERRY CUNNINGHAM
Title or Position: CEO
Credential:
Phone: 843-572-7727