Provider Demographics
NPI:1982029799
Name:SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type:Organization
Organization Name:SOUTH CAROLINA PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PERCIVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-285-1411
Mailing Address - Street 1:8141 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2845 E HIGHWAY 76
Practice Address - Street 2:MEDICAL PARK 2 STE 1
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6037
Practice Address - Country:US
Practice Address - Phone:843-431-2780
Practice Address - Fax:843-431-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC531213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty