Healthcare Provider Details

I. General information

NPI: 1639123961
Provider Name (Legal Business Name): JAMES WILEY ELLETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N SUMTER ST STE 300
SUMTER SC
29150-4972
US

IV. Provider business mailing address

3555 HARDEN STREET EXT 15 MEDICAL PARK, SUITE 300
COLUMBIA SC
29203-6894
US

V. Phone/Fax

Practice location:
  • Phone: 803-775-4655
  • Fax: 803-775-7258
Mailing address:
  • Phone: 803-434-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7442
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: