Healthcare Provider Details

I. General information

NPI: 1245623792
Provider Name (Legal Business Name): BLACK CREEK MEDICAL CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

696 MEDICAL PARK DR
HARTSVILLE SC
29550-4782
US

IV. Provider business mailing address

696 MEDICAL PARK DR
HARTSVILLE SC
29550-4782
US

V. Phone/Fax

Practice location:
  • Phone: 843-383-5312
  • Fax: 843-383-4516
Mailing address:
  • Phone: 843-383-5312
  • Fax: 843-383-4516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number27632
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number27632
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number27632
License Number StateSC

VIII. Authorized Official

Name: DR. ORVILLE HUGH DYCE
Title or Position: OWNER
Credential: MD
Phone: 18435682363