Provider Demographics
NPI:1568714053
Name:ALDERSON, THERESA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ROSE
Last Name:ALDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S SEVENTH ST
Mailing Address - Street 2:PO BOX 366
Mailing Address - City:MC BEE
Mailing Address - State:SC
Mailing Address - Zip Code:29101-7101
Mailing Address - Country:US
Mailing Address - Phone:843-335-8291
Mailing Address - Fax:843-335-8731
Practice Address - Street 1:40 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9406
Practice Address - Country:US
Practice Address - Phone:803-408-3262
Practice Address - Fax:803-408-8895
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27241208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC27241OtherSC LIC