Provider Demographics
NPI:1699190272
Name:SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type:Organization
Organization Name:SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PERCIVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-285-1411
Mailing Address - Street 1:8141 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:843-492-2293
Mailing Address - Fax:888-383-6797
Practice Address - Street 1:9789 CHARLOTTE HWY STE 200
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-7182
Practice Address - Country:US
Practice Address - Phone:803-548-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD593Medicare PIN
SC7097150014Medicare NSC