Healthcare Provider Details

I. General information

NPI: 1467438499
Provider Name (Legal Business Name): WALTERBORO ADULT AND PEDIATRIC MEDICINE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 SPRUCE ST
WALTERBORO SC
29488-2766
US

IV. Provider business mailing address

447 SPRUCE ST
WALTERBORO SC
29488-2766
US

V. Phone/Fax

Practice location:
  • Phone: 843-549-6331
  • Fax: 843-549-6332
Mailing address:
  • Phone: 843-549-6331
  • Fax: 843-549-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: MRS. CATHY MARIE MALPHRUS
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-549-6331