Provider Demographics
NPI:1124342506
Name:CAROLINA PHYSICAL MEDICINE AND
Entity type:Organization
Organization Name:CAROLINA PHYSICAL MEDICINE AND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:864-469-2045
Mailing Address - Street 1:958 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-2148
Mailing Address - Country:US
Mailing Address - Phone:864-542-0780
Mailing Address - Fax:864-542-1689
Practice Address - Street 1:958 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-2148
Practice Address - Country:US
Practice Address - Phone:864-542-0780
Practice Address - Fax:864-542-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC193200000XOtherTAXONOMY CODE
SC193200000XOtherTAXONOMY CODE
SC9593Medicare PIN