Basic Information
Provider Information | |||||||||
NPI: | 1487850780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCANN | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 743904 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303743904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032967320 | ||||||||
FaxNumber: | 8032967330 | ||||||||
Practice Location | |||||||||
Address1: | 6 RICHLAND MEDICAL PARK DR STE 2100 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292036864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034342762 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2007 | ||||||||
LastUpdateDate: | 06/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008022576 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 37187 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 390200000X | 2006015651 | MO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RA0001X | 37187 | SC | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 371872 | 05 | SC |   | MEDICAID |