Provider Demographics
NPI:1528601762
Name:FITCH, BAILEY MADISON (PA-C)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:MADISON
Last Name:FITCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:MADISON
Other - Last Name:HOLBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2145 HENRY TECKLENBURG DR STE 220
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5894
Practice Address - Country:US
Practice Address - Phone:843-723-8823
Practice Address - Fax:843-606-8059
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3599363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4244PAMedicaid