Provider Demographics
NPI:1992830632
Name:CAROLINA SURGICAL CLINIC, LLC
Entity Type:Organization
Organization Name:CAROLINA SURGICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-276-1866
Mailing Address - Street 1:2541 EVANS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2963
Mailing Address - Country:US
Mailing Address - Phone:803-276-1866
Mailing Address - Fax:803-276-1867
Practice Address - Street 1:2541 EVANS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2963
Practice Address - Country:US
Practice Address - Phone:803-276-1866
Practice Address - Fax:803-276-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28906261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC289066Medicaid
1194711283OtherNPI #
SC289066Medicaid