Basic Information
| Provider Information | |||||||||
| NPI: | 1730145509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELMAN | ||||||||
| FirstName: | OTIS | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2418 NNPTC CIRCLE | ||||||||
| Address2: | |||||||||
| City: | GOOSE CREEK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 OLD TROLLEY RD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294855293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438750400 | ||||||||
| FaxNumber: | 8438716700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8516 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 85160 | 05 | SC | MEDICAID | 410013918 | 01 | SC | MEDICARE RAIL ROAD | OTHER |