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 | 213ER0200X | Podiatrist | Radiology | 516 | SOUTH CAROLINA | No |
| 2 | 213ES0000X | Podiatrist | Sports Medicine | 516 | SOUTH CAROLINA | No |
| 3 | 213ES0131X | Podiatrist | Foot Surgery | 516 | SOUTH CAROLINA | No |
| 4 | 2471M1202X | Radiologic Technologist | Magnetic Resonance Imaging | 516 | SOUTH CAROLINA | No |
| 5 | 332B00000X | Durable Medical Equipment & Medical Supplies | | 516 | SOUTH CAROLINA | No |
| 6 | 332BC3200X | Durable Medical Equipment & Medical Supplies | Customized Equipment | 516 | SOUTH CAROLINA | No |
| 7 | 335E00000X | Prosthetic/Orthotic Supplier | | 516 | SOUTH CAROLINA | No |
| 8 | 213EP1101X | Podiatrist | Primary Podiatric Medicine | 516 | 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 | U-74396 | MEDICARE UPIN | SOUTH CAROLINA | |
| 2 | 4207850002 | MEDICARE NSC | | |
| 3 | U743960281 | MEDICARE PIN | SOUTH CAROLINA | |
| 4 | 42D2021725 | OTHER | SOUTH CAROLINA | CLIA CERTIFICATE OF WAIVER |
| 5 | 7238051 | OTHER | SOUTH CAROLINA | AETNA PROVIDER NO. |
| 6 | 1020003 | OTHER | SOUTH CAROLINA | ACM # MIDLANDS FOOT CL. |
