1013545722 NPI number — ABBY LEE REWOLDT MD

Table of content: ABBY LEE REWOLDT MD (NPI 1013545722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013545722 NPI number — ABBY LEE REWOLDT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REWOLDT
Provider First Name:
ABBY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1013545722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SINGLETON RIDGE RD
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-234-6946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6010 HIGHWAY 707
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29588-7321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-347-7216
Provider Business Practice Location Address Fax Number:
843-347-7218
Provider Enumeration Date:
03/29/2020

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: 207V00000X , with the licence number:  93431 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 934314 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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