Provider Demographics
NPI:1922111715
Name:SOUTH CAROLINA SPORTS MEDICINE & ORTHOPAEDIC CENTER
Entity Type:Organization
Organization Name:SOUTH CAROLINA SPORTS MEDICINE & ORTHOPAEDIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PIHLBLAD
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-569-3367
Mailing Address - Street 1:P.O. BOX 848316
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9100 MEDCOM STREET
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-569-3367
Practice Address - Fax:843-764-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0253030001OtherDMERIC ID
SCGP0078Medicaid
E20806Medicare UPIN
0253030001OtherDMERIC ID
SCGP0078Medicaid