Provider Demographics
NPI:1609252402
Name:CHARLESTON HEALTHSPAN INSTITUTE
Entity Type:Organization
Organization Name:CHARLESTON HEALTHSPAN INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KADY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-442-8915
Mailing Address - Street 1:900 ISLAND PARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492
Mailing Address - Country:US
Mailing Address - Phone:843-375-6588
Mailing Address - Fax:843-353-1610
Practice Address - Street 1:900 ISLAND PARK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492
Practice Address - Country:US
Practice Address - Phone:843-375-6588
Practice Address - Fax:843-353-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT30464Medicaid
NCG40086Medicare UPIN