Healthcare Provider Details

I. General information

NPI: 1407203300
Provider Name (Legal Business Name): ANNA MATRACHISIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA KUKHTA

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CALLEN BLVD STE 220
SUMMERVILLE SC
29486-2816
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-958-1281
  • Fax: 843-958-1278
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number39423
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101275631
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: