Healthcare Provider Details

I. General information

NPI: 1881045128
Provider Name (Legal Business Name): AMANDA FLY POPE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MEDICAL PKWY STE 100
GREER SC
29650-2456
US

IV. Provider business mailing address

112 CORNELSON DR
GREER SC
29651-1264
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number1030
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: