Provider Demographics
NPI:1063692457
Name:EDISTO UROLOGICAL ASSOCIATES
Entity type:Organization
Organization Name:EDISTO UROLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-534-4611
Mailing Address - Street 1:1175 COOK RD STE 310
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-534-4611
Mailing Address - Fax:803-534-7269
Practice Address - Street 1:1175 COOK RD STE 310
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-534-4611
Practice Address - Fax:803-534-7269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5227208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD99222Medicare UPIN
SC1898Medicare PIN