Healthcare Provider Details

I. General information

NPI: 1528028602
Provider Name (Legal Business Name): DANIEL SCOT KOELE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 E HIGHWAY 76
MULLINS SC
29574-6035
US

IV. Provider business mailing address

420 W CAROLINA AVE
HARTSVILLE SC
29550-4524
US

V. Phone/Fax

Practice location:
  • Phone: 843-431-2000
  • Fax:
Mailing address:
  • Phone: 843-917-4977
  • Fax: 888-854-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberA590
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: