=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659320695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY R CANTILLION MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 11/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 SAINT FRANCIS DR STE 310 BON SECOURS PHYSICAL MEDICINE & REHAB
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-3968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-255-1920
-----------------------------------------------------
Fax | 864-679-8766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 743294
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-3294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-255-1920
-----------------------------------------------------
Fax | 864-679-8766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 27319
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------