Provider Demographics
NPI:1790949790
Name:HADDAD, BASSAM E (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:E
Last Name:HADDAD
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 1:1120 SPARKLEBERRY LANE EXT STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7078
Mailing Address - Country:US
Mailing Address - Phone:803-851-0605
Mailing Address - Fax:866-291-3617
Practice Address - Street 1:2076 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-373-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC31026OtherMED LICENSE
SCPG1133Medicaid