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General NPI Number Information
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NPI Number | 1659560407
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Entity Type | Organization
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Legal Business Name | PLASTIC & RECONSTRUCTIVE SURGERY OF SUMTER, PA
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 18 MILLER RD
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City | SUMTER
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State | SC
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Zip | 29150-2403
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Country | US
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Telephone | 803-773-6361
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Fax | 803-773-6009
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Provider Business Mailing Address
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Address Line | 18 MILLER RD
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City | SUMTER
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State | SC
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Zip | 29150-2403
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Country | US
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Telephone | 803-773-6361
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Fax | 803-773-6009
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY R. CULBERTSON
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Credential | M.D.
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Telephone | 803-773-6361
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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 | 17109
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License Number State | SC
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