Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 208VP0014X | Pain Medicine | Interventional Pain Medicine | 0412 | SOUTH CAROLINA | No |
| 2 | 2084N0400X | Psychiatry & Neurology | Neurology | 0412 | SOUTH CAROLINA | No |
| 3 | 2084P0800X | Psychiatry & Neurology | Psychiatry | 0412 | SOUTH CAROLINA | No |
| 4 | 2084S0012X | Psychiatry & Neurology | Sleep Medicine | 0412 | SOUTH CAROLINA | No |
| 5 | 2084P2900X | Psychiatry & Neurology | Pain Medicine | 0412 | SOUTH CAROLINA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 2075807 | OTHER | SOUTH CAROLINA | AETNA HMO NETWORK |
| 2 | #11 | OTHER | SOUTH CAROLINA | UNITED HEALTH CARE |
| 3 | 2075537001 | OTHER | SOUTH CAROLINA | CIGNA |
| 4 | 263154 | OTHER | SOUTH CAROLINA | ONE HEALTH PLAN |
| 5 | 5385300 | OTHER | SOUTH CAROLINA | HEALTHSOURCE/CIGNA |
| 6 | 5888629 | OTHER | SOUTH CAROLINA | AETNA OPEN NETWORK |
| 7 | G09973 | MEDICARE UPIN | SOUTH CAROLINA | |
| 8 | 3099822 | OTHER | NEW YORK | GHI |
| 9 | 709566 | OTHER | SOUTH CAROLINA | FOCUS |
| 10 | 720502 | OTHER | SOUTH CAROLINA | MI EVOLUTIONS |
| 11 | 004122 | MEDICAID | SOUTH CAROLINA | |
| 12 | 01839317 | MEDICAID | PENNSYLVANIA | |
| 13 | 1044180 | OTHER | SOUTH CAROLINA | FIRST HEALTH |
| 14 | 720503 | OTHER | SOUTH CAROLINA | MB EVOLUTIONS |
| 15 | 0503624 | OTHER | SOUTH CAROLINA | PHYSICIANS HEALTH PLAN |
| 16 | 7905104 | MEDICAID | NORTH CAROLINA | |
| 17 | 60806 | OTHER | SOUTH CAROLINA | MEDCOST |