Provider Demographics
NPI:1851424816
Name:CAROLINA PODIATRY GROUP, INC.
Entity Type:Organization
Organization Name:CAROLINA PODIATRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:PERCIVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-285-1411
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721-0325
Mailing Address - Country:US
Mailing Address - Phone:803-285-1411
Mailing Address - Fax:803-283-9920
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:BLDG 3 SUITE C
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-9769
Practice Address - Country:US
Practice Address - Phone:800-336-1279
Practice Address - Fax:803-283-9920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9953Medicaid
SCPD5364Medicaid
SCPD5408Medicaid
SCPD5408Medicaid
SC1013103100Medicare UPIN
SC6505Medicare PIN
SCGP9953Medicaid