Provider Demographics
NPI:1508891474
Name:MCCOLLOUGH, WILMOT S III (MD)
Entity Type:Individual
Prefix:
First Name:WILMOT
Middle Name:S
Last Name:MCCOLLOUGH
Suffix:III
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:803-435-5270
Mailing Address - Fax:803-433-0154
Practice Address - Street 1:10 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3153
Practice Address - Country:US
Practice Address - Phone:803-435-8463
Practice Address - Fax:803-435-5288
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10886208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD99117Medicare UPIN
SCAA5559Medicare PIN