Healthcare Provider Details

I. General information

NPI: 1386394500
Provider Name (Legal Business Name): MARY WURZELMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

701 GROVE RD
GREENVILLE SC
29605-4210
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-5198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLL88124
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: