Provider Demographics
NPI:1063444347
Name:CAROLINA FAMILY PRACTICE
Entity Type:Organization
Organization Name:CAROLINA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:803-777-3861
Mailing Address - Street 1:PO BOX 5731
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250-5731
Mailing Address - Country:US
Mailing Address - Phone:803-256-2500
Mailing Address - Fax:803-758-1726
Practice Address - Street 1:1410 BLANDING ST STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-256-2500
Practice Address - Fax:803-777-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3197Medicaid
SC6580Medicare PIN
SC6581Medicare PIN
SCGP3197Medicaid