Healthcare Provider Details

I. General information

NPI: 1588618144
Provider Name (Legal Business Name): EXCELSIOR MEDICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 N MAIN ST EXCELSIOR MEDICAL CLINIC, PA
SUMTER SC
29150-4233
US

IV. Provider business mailing address

448 N MAIN ST EXCELSIOR MEDICAL CLINIC, PA
SUMTER SC
29150-4233
US

V. Phone/Fax

Practice location:
  • Phone: 803-778-2429
  • Fax: 803-773-6303
Mailing address:
  • Phone: 803-778-2429
  • Fax: 803-773-6303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9647
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9646
License Number StateSC

VIII. Authorized Official

Name: DR. JOSEPH CECIL WILLIAMS
Title or Position: PRESIDENT
Credential: MD
Phone: 803-778-2429