Healthcare Provider Details

I. General information

NPI: 1104888403
Provider Name (Legal Business Name): ABNER H BAGENSTOSE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 RIBAUT RD
PORT ROYAL SC
29935-1118
US

IV. Provider business mailing address

721 OKATIE HWY
OKATIE SC
29909-3963
US

V. Phone/Fax

Practice location:
  • Phone: 843-986-0900
  • Fax:
Mailing address:
  • Phone: 843-987-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number32682
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32682
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: