1447298906 NPI number — LOW COUNTRY UROLOGY, P.A.

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 1447298906 NPI number — LOW COUNTRY UROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOW COUNTRY UROLOGY, P.A.
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:
Provider Other Organization Name Type Code:
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:
1447298906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1580 FREEDOM BLVD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29505-6074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-661-0402
Provider Business Mailing Address Fax Number:
843-661-0960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 FREEDOM BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29505-6074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-661-0402
Provider Business Practice Location Address Fax Number:
843-661-0960
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
O'KELLY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
KEVIN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
843-661-0402

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  163156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP1485 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 163156 . This is a "SC LICENSE NUMBER" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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