=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104491984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARETEAM HEALTH SC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2021
-----------------------------------------------------
Last Update Date | 05/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 ARSENAL ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472-2782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-402-2157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1875
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29465-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-371-1471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MATTHEW THEODORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-729-0316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------