1295149631 NPI number — GEORGETOWN PHYSICIAN ASSOCIATES, LLC

Table of content: (NPI 1295149631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295149631 NPI number — GEORGETOWN PHYSICIAN ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGETOWN PHYSICIAN ASSOCIATES, 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:
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:
1295149631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421718
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:
29442-4203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-520-8883
Provider Business Mailing Address Fax Number:
843-652-8422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4040 HIGHWAY 17 UNIT 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-5098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-652-8150
Provider Business Practice Location Address Fax Number:
843-652-8151
Provider Enumeration Date:
06/13/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP6524 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com