Provider Demographics
NPI:1699832089
Name:CHARLESTON SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:CHARLESTON SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE FACILITATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-577-7550
Mailing Address - Street 1:125 DOUGHTY ST
Mailing Address - Street 2:SUITE 660
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5736
Mailing Address - Country:US
Mailing Address - Phone:843-577-7550
Mailing Address - Fax:843-853-5588
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 660
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5736
Practice Address - Country:US
Practice Address - Phone:843-577-7550
Practice Address - Fax:843-853-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA7395Medicaid
SCPA7395Medicaid