Provider Demographics
NPI:1932398559
Name:W WALLACE VAUGHT JR MD PC
Entity Type:Organization
Organization Name:W WALLACE VAUGHT JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:W WALLACE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-665-2000
Mailing Address - Street 1:800 E CHEVES ST
Mailing Address - Street 2:STE 350
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2650
Mailing Address - Country:US
Mailing Address - Phone:843-665-2000
Mailing Address - Fax:843-669-1701
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:STE 350
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2650
Practice Address - Country:US
Practice Address - Phone:843-665-2000
Practice Address - Fax:843-669-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13703208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC137033Medicaid
SC137033Medicaid