Healthcare Provider Details

I. General information

NPI: 1114136694
Provider Name (Legal Business Name): CARDIOVASCULAR ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 11/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 CAROLINA AVE
ORANGEBURG SC
29115-4940
US

IV. Provider business mailing address

1595 CAROLINA AVE
ORANGEBURG SC
29115-4940
US

V. Phone/Fax

Practice location:
  • Phone: 803-534-3092
  • Fax: 803-531-4698
Mailing address:
  • Phone: 803-534-3092
  • Fax: 803-531-4698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES LEROY WELLS JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 803-534-3092