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General NPI Number Information
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NPI Number | 1225120264
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Entity Type | Organization
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Legal Business Name | CHARLESTON BLOOD DISORDERS & CANCER CENTER, P.A.
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 07/21/2010
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Provider Practice Location Address
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Address Line | 2093 HENRY TECKLENBURG DRIVE SUITE318E
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City | CHARLESTON
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State | SC
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Zip | 29414
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Country | US
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Telephone | 843-582-0266
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Fax | 843-852-2025
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Provider Business Mailing Address
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Address Line | 2093 HENRY TECKLENBURG DRIVE SUITE318E
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City | CHARLESTON
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State | SC
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Zip | 29414
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Country | US
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Telephone | 843-582-0266
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Fax | 843-852-2025
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT T WALL JR.
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Credential | M.D.
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Telephone | 843-852-0266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 20-11042
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License Number State | SC
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