=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407203300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA MATRACHISIA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2016
-----------------------------------------------------
Last Update Date | 09/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 CALLEN BLVD STE 220
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29486-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-958-1281
-----------------------------------------------------
Fax | 843-958-1278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 751649
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28275-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-472-0043
-----------------------------------------------------
Fax | 843-724-2440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 39423
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 0101275631
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------