Healthcare Provider Details

I. General information

NPI: 1922111715
Provider Name (Legal Business Name): SOUTH CAROLINA SPORTS MEDICINE & ORTHOPAEDIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 MEDCOM ST
N CHARLESTON SC
29406-9188
US

IV. Provider business mailing address

9100 MEDCOM ST
NORTH CHARLESTON SC
29406-9188
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-2663
  • Fax: 843-764-3577
Mailing address:
  • Phone: 843-569-3367
  • Fax: 843-764-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW PIHLBLAD MCWILLIAMS
Title or Position: CFO
Credential:
Phone: 843-569-3367