Provider Demographics
NPI:1932421385
Name:CAROLINA PODIATRY CLINIC LLC
Entity Type:Organization
Organization Name:CAROLINA PODIATRY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KSOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:864-494-0534
Mailing Address - Street 1:2604 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2240
Mailing Address - Country:US
Mailing Address - Phone:803-425-5510
Mailing Address - Fax:803-432-4776
Practice Address - Street 1:2502 BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020
Practice Address - Country:US
Practice Address - Phone:803-425-5510
Practice Address - Fax:803-432-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC563213EP1101X
SCDE3794332B00000X
SC6460510001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9894Medicaid
SCDQ3852OtherRR MEDICARE
SC6460510001Medicare NSC
SCDQ3852OtherRR MEDICARE