Provider Demographics
NPI:1063680197
Name:CAROLINA GASTROENTEROLOGY & NUTRITION CLINICS, LLC
Entity Type:Organization
Organization Name:CAROLINA GASTROENTEROLOGY & NUTRITION CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BICKERSTAFF
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-762-9321
Mailing Address - Street 1:102 WAPPOO CREEK DR STE 10C
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2144
Mailing Address - Country:US
Mailing Address - Phone:843-762-9321
Mailing Address - Fax:843-377-1580
Practice Address - Street 1:102 WAPPOO CREEK DR STE 10C
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412
Practice Address - Country:US
Practice Address - Phone:843-762-9321
Practice Address - Fax:843-377-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC086597Medicaid
SC7734Medicare UPIN