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General NPI Number Information
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NPI Number | 1265232326
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Entity Type | Organization
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Legal Business Name | BULL ST. DISTRICT FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 03/18/2025
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Last Update Date | 03/18/2025
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Provider Practice Location Address
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Address Line | 1417 GREGG ST
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City | COLUMBIA
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State | SC
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Zip | 29201-3527
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Country | US
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Telephone | 803-915-0469
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 99
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City | COLUMBIA
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State | SC
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Zip | 29202-0099
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Country | US
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Telephone | 803-915-0469
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Fax |
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | DR. CORNELL MAURICE CLARK
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Credential | M.D.
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Telephone | 702-904-4077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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