1740230283 NPI number — MRS. MARY RAVENEL ANDERSON OTLR

Table of content: MRS. MARY RAVENEL ANDERSON OTLR (NPI 1740230283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740230283 NPI number — MRS. MARY RAVENEL ANDERSON OTLR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
MARY
Provider Middle Name:
RAVENEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTLR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740230283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
586 LONE TREE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-402-1495
Provider Business Mailing Address Fax Number:
843-402-1285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1941 SAVAGE ROAD
Provider Second Line Business Practice Location Address:
STE 300A
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-402-1495
Provider Business Practice Location Address Fax Number:
843-402-1285
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP1753 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: TH0691 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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