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General NPI Number Information
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NPI Number | 1013550169
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Entity Type | Organization
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Legal Business Name | MDASPECT SC
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Dates
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Enumeration Date | 10/22/2019
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Last Update Date | 10/22/2019
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Provider Practice Location Address
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Address Line | 913 BOWMAN RD STE 104
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City | MOUNT PLEASANT
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State | SC
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Zip | 29464-3235
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Country | US
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Telephone | 919-210-6775
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Fax | 828-327-2597
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Provider Business Mailing Address
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Address Line | PO BOX 20083
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City | CHARLOTTE
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State | NC
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Zip | 28202-0027
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Country | US
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Telephone | 919-210-6775
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Fax | 828-327-2597
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Authorized Official
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Title or Position | PARTNER
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Name | ROY DICKERSON IV
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Credential |
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Telephone | 919-210-6775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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