Healthcare Provider Details

I. General information

NPI: 1639492952
Provider Name (Legal Business Name): EDWARD CLARK BURNSIDE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 EWALL ST
MT PLEASANT SC
29464-3046
US

IV. Provider business mailing address

PO BOX 81113 ASHLEY RIVER STATION
CHARLESTON SC
29416-1113
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-0499
  • Fax: 843-388-6292
Mailing address:
  • Phone: 843-573-0499
  • Fax: 843-388-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTL 1511
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: