Healthcare Provider Details

I. General information

NPI: 1730182932
Provider Name (Legal Business Name): BENJAMIN BLAKE WEATHERSBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 FABER PLACE DR
NORTH CHARLESTON SC
29405-8533
US

IV. Provider business mailing address

3815 FABER PLACE DR
CHARLESTON SC
29405-8533
US

V. Phone/Fax

Practice location:
  • Phone: 843-767-9312
  • Fax: 843-767-9313
Mailing address:
  • Phone: 843-767-9312
  • Fax: 843-767-9313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number23772
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: