Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 4068 | SC |
NPI | 1780690289 |
---|---|
Provider Name | Dr. Walter R. Main |
First Address | Cheraw, SC 29520-2636 |
Second Address | Cheraw, SC 29520-2636 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 07/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
048240 | HEALTH ALLIANCE (01) | IL |
5722676 | BLUE CROSS/BLUE SHIELD IN (01) | IL |
7862458 | AETNA INSURANCE (01) | IL |
U49905 | (02) | IL |