Healthcare Provider Details

I. General information

NPI: 1134150691
Provider Name (Legal Business Name): SHILAND FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/05/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 RIVERCHASE BLVD SUITE 2400
ROCK HILL SC
29732-2084
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-5131
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RISSMILLER
Title or Position: ENTERPRISE EVP
Credential:
Phone: 704-355-8675