MEDICARE: DR. KRISTINA P HURSEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	M0762	TX
2	207R00000X	Internal Medicine Physician	31369	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00382491	OTHER		RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	M0762	OTHER	TX	STATE LICENSE #

General Provider Information

NPI Number	:	1124070768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTINA P HURSEY MD

Provider Business Mailing Address
First Line	:	PO BOX 896239
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28289-6239
Country	:	US
Telephone Number	:	803-865-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 GATEWAY CORNERS PARK
Second Line	:	SUITE 101
City	:	COLUMBIA
State	:	SC
Zip	:	29203-8906
Country	:	US
Telephone Number	:	803-865-2122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/21/2022

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