Healthcare Provider Details

I. General information

NPI: 1114963188
Provider Name (Legal Business Name): MARIA RUDISILL STRECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 BEN SAWYER BLVD
MT PLEASANT SC
29464-5525
US

IV. Provider business mailing address

PO BOX 602108
CHARLOTTE NC
28260-2108
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-8333
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number38389
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number19404
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30868
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number30868
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberTL30868
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: