MEDICARE: W PETTIGREW CLARE

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	5058	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	57-051956	OTHER	SC	TAX IDENTIFICATION

General Provider Information

NPI Number	:	1932223179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W PETTIGREW CLARE

Provider Business Mailing Address
First Line	:	1155 FORT LAMAR RD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-9683
Country	:	US
Telephone Number	:	843-762-3550
Fax Number	:	843-795-8945

Provider Business Practice Location Address
First Line	:	1155 FORT LAMAR RD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-9683
Country	:	US
Telephone Number	:	843-762-3550
Fax Number	:	843-795-8945

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM PETTIGREW CLARE
Credential	:	MD
Telephone Number	:	843-762-3550

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	08/22/2020

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