Healthcare Provider Details

I. General information

NPI: 1598002891
Provider Name (Legal Business Name): ELIZABETH DOUGLAS JOSEPH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN DOUGLAS PA

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 S HIGHWAY 14
GREENVILLE SC
29615-6138
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-627-8878
  • Fax:
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1891
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: