Healthcare Provider Details

I. General information

NPI: 1225593924
Provider Name (Legal Business Name): MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 E HIGHWAY 76 STE 5
MULLINS SC
29574-6037
US

IV. Provider business mailing address

PO BOX 936801
ATLANTA GA
31193-6801
US

V. Phone/Fax

Practice location:
  • Phone: 843-431-2650
  • Fax:
Mailing address:
  • Phone: 843-792-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
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: KARYN RAE
Title or Position: DIRECTOR
Credential:
Phone: 843-876-1344