Healthcare Provider Details

I. General information

NPI: 1740402130
Provider Name (Legal Business Name): ST PAUL'S MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 HIGHWAY 164
HOLLYWOOD SC
29449
US

IV. Provider business mailing address

PO BOX 1355
HOLLYWOOD SC
29449-1355
US

V. Phone/Fax

Practice location:
  • Phone: 843-889-8018
  • Fax: 843-889-9133
Mailing address:
  • Phone: 843-889-8018
  • Fax: 843-889-9133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARSHA GAY DELAVAN
Title or Position: PRESIDENT
Credential: PA-C
Phone: 843-889-8018