Provider Demographics
NPI:1841483344
Name:EDSALL, CHARLES KENNETH I (M D)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:KENNETH
Last Name:EDSALL
Suffix:I
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-6140
Mailing Address - Fax:864-512-6149
Practice Address - Street 1:100 HEALTHY WAY STE 1200
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-512-6140
Practice Address - Fax:864-512-6149
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29929207Q00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1841483344OtherNPI
SC299297Medicaid