=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821466202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP ANDREWS REATH PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2015
-----------------------------------------------------
Last Update Date | 03/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 RICHLAND MEDICAL PARK DR SUITE 100
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-434-3800
-----------------------------------------------------
Fax | 803-744-2759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 EXCHANGE DR
-----------------------------------------------------
City | LUGOFF
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29078-9198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-424-2207
-----------------------------------------------------
Fax | 803-408-3282
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2389
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------