MEDICARE: MR. SANTTANU MCDANIEL SR. PTA

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	225200000X	Physical Therapy Assistant	4659	SC

General Provider Information

NPI Number	:	1275107740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANTTANU MCDANIEL SR. PTA

Provider Business Mailing Address
First Line	:	109 LOGGERHEAD DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-7909
Country	:	US
Telephone Number	:	803-529-9166
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 GATEWAY CORNERS PARK STE 102
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-8906
Country	:	US
Telephone Number	:	803-699-9775
Fax Number	:

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

Provider Enumeration Date	:	05/18/2021
Last Update Date	:	05/18/2021

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