Provider Demographics
NPI:1588618144
Name:EXCELSIOR MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:EXCELSIOR MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CECIL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-778-2429
Mailing Address - Street 1:448 N MAIN ST
Mailing Address - Street 2:EXCELSIOR MEDICAL CLINIC, PA
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4233
Mailing Address - Country:US
Mailing Address - Phone:803-778-2429
Mailing Address - Fax:803-773-6303
Practice Address - Street 1:448 N MAIN ST
Practice Address - Street 2:EXCELSIOR MEDICAL CLINIC, PA
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4233
Practice Address - Country:US
Practice Address - Phone:803-778-2429
Practice Address - Fax:803-773-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9647207R00000X
SC9646208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA5850Medicaid
SC2460Medicare PIN