Provider Demographics
NPI:1578596995
Name:LATOURETTE, PHILIP CARL (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CARL
Last Name:LATOURETTE
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 1:1325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3860
Mailing Address - Country:US
Mailing Address - Phone:864-725-4095
Mailing Address - Fax:864-725-5082
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4095
Practice Address - Fax:864-725-5082
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20645208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC206459Medicaid
SC206459Medicaid
SCF134655640Medicare PIN
SC571049338OtherBCBS
NC013KEOtherBCBS
SCGP1456Medicaid
NC2005685Medicare PIN
NC2005685BMedicare PIN
SCGP2967Medicaid
NC013KEMedicaid