Provider Demographics
NPI:1467438499
Name:WALTERBORO ADULT AND PEDIATRIC MEDICINE,LLC
Entity Type:Organization
Organization Name:WALTERBORO ADULT AND PEDIATRIC MEDICINE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MALPHRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-549-6331
Mailing Address - Street 1:447 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2766
Mailing Address - Country:US
Mailing Address - Phone:843-549-6331
Mailing Address - Fax:843-549-6332
Practice Address - Street 1:447 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2766
Practice Address - Country:US
Practice Address - Phone:843-549-6331
Practice Address - Fax:843-549-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3911Medicaid
SC7910Medicare ID - Type UnspecifiedGROUP NUMBER