Healthcare Provider Details

I. General information

NPI: 1285702498
Provider Name (Legal Business Name): IRINA BORISSOVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PROFESSIONAL VILLAGE CIR
LADYS ISLAND SC
29907-1569
US

IV. Provider business mailing address

12 PROFESSIONAL VILLAGE CIR
LADYS ISLAND SC
29907-1569
US

V. Phone/Fax

Practice location:
  • Phone: 843-524-6829
  • Fax: 843-524-6820
Mailing address:
  • Phone: 843-524-6829
  • Fax: 843-524-5820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: IRINA BORISSOVA
Title or Position: MD
Credential: MD
Phone: 843-524-6829