Provider Demographics
NPI:1528078862
Name:CARRUTHERS, MARY W (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:CARRUTHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11450
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1450
Mailing Address - Country:US
Mailing Address - Phone:800-509-8102
Mailing Address - Fax:
Practice Address - Street 1:401 NORTH LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-761-8721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26486207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC264868Medicaid
SC264868Medicaid
SCP00151691Medicare PIN
H72172Medicare UPIN
SCH721722986Medicare PIN