# BULL ST. DISTRICT FAMILY PRACTICE LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Bull St District Family Practice, Cornell M. Clark, M.D.
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265232326
- **Authorized official:** DR. CORNELL MAURICE CLARK M.D. (MANAGING DIRECTOR)
- **Authorized official phone:** (702) 904-4077

## Contact information

- **Practice address:** 1417 GREGG ST, COLUMBIA, SC 29201-3527
- **Practice address phone:** (803) 915-0469
- **Mailing address:** PO BOX 99, COLUMBIA, SC 29202-0099
- **Mailing address phone:** (803) 915-0469

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | — | NULL | Yes |
| 207QA0505X | Adult Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 03/18/2025
- **Last updated:** 03/18/2025