Provider Demographics
NPI:1922055649
Name:CAROLINA ORTHOPAEDIC AND SPORTS MEDICINE, P.A.
Entity Type:Organization
Organization Name:CAROLINA ORTHOPAEDIC AND SPORTS MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-782-4278
Mailing Address - Street 1:PO BOX 890046
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0046
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:1818 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2619
Practice Address - Country:US
Practice Address - Phone:803-758-2600
Practice Address - Fax:803-253-8896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4222Medicaid
8455Medicare ID - Type Unspecified