Basic Information
| Provider Information | |||||||||
| NPI: | 1962450791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRESSLER | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 RUNNING FOX RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292233018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037881965 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 TAYLOR ST | ||||||||
| Address2: | ST. 7B | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032549461 | ||||||||
| FaxNumber: | 8032549318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10204 | SC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 102043 | 05 | SC | MEDICAID |