Healthcare Provider Details

I. General information

NPI: 1821144304
Provider Name (Legal Business Name): PHYLLIS J KUTCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 JENKINS STREET
MAULDIN SC
29662-2412
US

IV. Provider business mailing address

11 JENKINS ST
MAULDIN SC
29662-2412
US

V. Phone/Fax

Practice location:
  • Phone: 864-288-1941
  • Fax: 864-288-1946
Mailing address:
  • Phone: 864-288-1941
  • Fax: 864-288-1946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1165
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: