1083275366 NPI number — TIDELANDS AND MEDQUEST JOINT VENTURE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083275366 NPI number — TIDELANDS AND MEDQUEST JOINT VENTURE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDELANDS AND MEDQUEST JOINT VENTURE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIDELANDS HEALTH IMAGING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083275366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 BLACK RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29440-3304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-527-7000
Provider Business Mailing Address Fax Number:
843-652-8032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 21ST AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-7483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-916-1700
Provider Business Practice Location Address Fax Number:
843-916-9460
Provider Enumeration Date:
06/26/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
EVP & CFO
Authorized Official Telephone Number:
843-527-7102

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)