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 | 207Q00000X | Family Medicine | | 18850 | SOUTH CAROLINA | No |
| 2 | 207QH0002X | Family Medicine | Hospice and Palliative Medicine | 9701245 | NORTH CAROLINA | No |
| 3 | 207Q00000X | Family Medicine | | 9701245 | NORTH 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 | P01077510 | OTHER | SOUTH CAROLINA | RAILROAD MEDICARE |
| 2 | 891345U | MEDICAID | NORTH CAROLINA | |
| 3 | 1345U | OTHER | NORTH CAROLINA | BCBS PROVIDER NUMBER |
| 4 | P00362116 | OTHER | NORTH CAROLINA | MEDICARE RAILROAD PROVIDE |
| 5 | AA57365019 | MEDICARE PIN | SOUTH CAROLINA | |
| 6 | 1518961275 | MEDICAID | NORTH CAROLINA | |
| 7 | G77485 | MEDICARE UPIN | NORTH CAROLINA | |
| 8 | 2022149 | MEDICARE PIN | NORTH CAROLINA | |
| 9 | 188503 | MEDICAID | SOUTH CAROLINA | |
