Provider Demographics
NPI:1730145509
Name:ENGELMAN, OTIS EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:EDWARD
Last Name:ENGELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 NNPTC CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:
Practice Address - Street 1:1101 OLD TROLLEY RD
Practice Address - Street 2:STE. 100
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5293
Practice Address - Country:US
Practice Address - Phone:843-875-0400
Practice Address - Fax:843-871-6700
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC85160Medicaid
SC410013918OtherMEDICARE RAIL ROAD
SCSC11647499Medicare PIN
SC85160Medicaid
SCSC11645281Medicare PIN
SCB921227555Medicare PIN
SCB921228798Medicare PIN
SCB921227126Medicare PIN
SCB921225277Medicare UPIN
SCB921225282Medicare PIN
SCB921227555Medicare PIN