Provider Demographics
NPI:1518930940
Name:BOULWARE, WILLIAM N (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:N
Last Name:BOULWARE
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 1:501 S COIT ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5220
Mailing Address - Country:US
Mailing Address - Phone:843-665-2191
Mailing Address - Fax:843-679-0818
Practice Address - Street 1:501 S COIT ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5220
Practice Address - Country:US
Practice Address - Phone:843-665-2191
Practice Address - Fax:843-679-0818
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC103845Medicaid
SC103845Medicaid
SCB916998712Medicare PIN