1265592117 NPI number — MCCREA EWART MD PA

Table of content: (NPI 1184154247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265592117 NPI number — MCCREA EWART MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCREA EWART MD PA
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:
6
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:
1265592117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1519
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:
29442-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-527-1331
Provider Business Mailing Address Fax Number:
843-527-1332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 A N FRASER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-527-1331
Provider Business Practice Location Address Fax Number:
843-527-1332
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EWART
Authorized Official First Name:
JACKSON
Authorized Official Middle Name:
MCCREA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
843-527-1331

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  8834 , 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: PA9491 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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