Provider Demographics
NPI:1154304632
Name:SACCOGNA, PHILLIP W (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:W
Last Name:SACCOGNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WHITMIRE RD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-1426
Mailing Address - Country:US
Mailing Address - Phone:864-855-2411
Mailing Address - Fax:864-855-2413
Practice Address - Street 1:115 WHITMIRE RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1426
Practice Address - Country:US
Practice Address - Phone:864-855-2411
Practice Address - Fax:864-855-2413
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17947174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA7876Medicaid
SC2424Medicare ID - Type UnspecifiedMEDICARE ID #
SCG05199Medicare UPIN