Provider Demographics
NPI:1710298153
Name:BASHOUR, SHADI M (DO)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:M
Last Name:BASHOUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S RAVENEL ST STE 120
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2619
Mailing Address - Country:US
Mailing Address - Phone:843-777-7290
Mailing Address - Fax:843-777-7280
Practice Address - Street 1:1100 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2708
Practice Address - Country:US
Practice Address - Phone:843-669-6694
Practice Address - Fax:843-669-2500
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018765207R00000X
SCDO37715207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine