=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871924167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOCUS SC 1009, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2013
-----------------------------------------------------
Last Update Date | 04/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 BOWMAN RD SUITE 303
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-593-9332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 BOWMAN RD SUITE 303
-----------------------------------------------------
City | MT. PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-593-9332
-----------------------------------------------------
Fax | 251-414-5809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES C WILEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 251-301-8276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0006X
-----------------------------------------------------
Taxonomy Name | Developmental - Behavioral Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------