Healthcare Provider Details

I. General information

NPI: 1033774633
Provider Name (Legal Business Name): BRUCE PALMER FRESHLEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 09/18/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3793 MCDOWELL LANE STE 100
LITTLE RIVER SC
29566-7892
US

IV. Provider business mailing address

506 E CHEVES ST STE 202
FLORENCE SC
29506-2616
US

V. Phone/Fax

Practice location:
  • Phone: 843-390-0100
  • Fax: 843-390-0038
Mailing address:
  • Phone: 843-390-0100
  • Fax: 843-390-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94991
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number94991
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number82649
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: