Provider Demographics
NPI:1184118861
Name:MICOLUCCI, SAVANNAH WILLIAMS (MD)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:WILLIAMS
Last Name:MICOLUCCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:101 HALTON VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6825
Practice Address - Country:US
Practice Address - Phone:864-455-1600
Practice Address - Fax:834-286-5298
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52773207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC527736Medicaid