Basic Information
| Provider Information | |||||||||
| NPI: | 1821466202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REATH | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | ANDREWS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 EXCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | LUGOFF | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290789198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034242207 | ||||||||
| FaxNumber: | 8034083282 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343800 | ||||||||
| FaxNumber: | 8037442759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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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 | 363AM0700X | 2389 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2929PA | 05 | SC | MEDICAID | SC79579988 | 01 | SC | MEDICARE | OTHER |