=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265502744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA WOMENS CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 07/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104B MORGAN PLACE
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-851-3800
-----------------------------------------------------
Fax | 843-851-7787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50367
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-851-3800
-----------------------------------------------------
Fax | 843-851-7787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. TINA M MITCHUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-851-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number | 10650BG
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 10650BG
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------