Provider Demographics
NPI:1750473096
Name:MACI, ENON (MD)
Entity Type:Individual
Prefix:
First Name:ENON
Middle Name:
Last Name:MACI
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 1:9330 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9104
Mailing Address - Country:US
Mailing Address - Phone:843-847-3225
Mailing Address - Fax:843-847-3247
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:843-847-3225
Practice Address - Fax:843-847-3247
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241487207R00000X
SC30161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301612Medicaid
SCAA27798580Medicare PIN