Provider Demographics
NPI:1194026153
Name:MEDICAL UNIVERSITY OF SC
Entity Type:Organization
Organization Name:MEDICAL UNIVERSITY OF SC
Other - Org Name:DIVISION OF ORAL PATHOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF DIVISION OF ORAL PATHOL
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:W
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-792-4496
Mailing Address - Street 1:MSC 507 173 ASHLEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-0001
Mailing Address - Country:US
Mailing Address - Phone:843-792-4495
Mailing Address - Fax:843-792-3697
Practice Address - Street 1:173 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-4495
Practice Address - Fax:843-792-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX0019Medicaid
SC2375Medicaid
T236980281Medicare PIN
AA05570281Medicare PIN