=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205518792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AD OF SOUTH CAROLINA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2023
-----------------------------------------------------
Last Update Date | 09/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E BAY ST STE 201K
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29401-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-851-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 95000 - 8642
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19195-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-851-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC. VP OF OPERATIONS
-----------------------------------------------------
Name | LAURA ADKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-424-0869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------