Provider Demographics
NPI:1184681579
Name:TABOR, MARCELLA ANN (DO)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:ANN
Last Name:TABOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-3433
Mailing Address - Country:US
Mailing Address - Phone:407-447-7120
Mailing Address - Fax:833-994-1101
Practice Address - Street 1:1213 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-3433
Practice Address - Country:US
Practice Address - Phone:407-447-7120
Practice Address - Fax:833-994-1101
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080107585OtherRR MEDICARE
SCSC2318I818OtherMEDICARE PIN
SCT00656Medicaid
SCGP1551OtherMEDICAID GROUP
SCSC23187126Medicare PIN
SCD046495277Medicare PIN
SCD046495277Medicare PIN