1790972867 NPI number — LOWCOUNTRY UROLOGY CLINICS, PA

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 1790972867 NPI number — LOWCOUNTRY UROLOGY CLINICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOWCOUNTRY UROLOGY CLINICS, 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:
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:
1790972867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2687 LAKE PARK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N. CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29406-9100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-725-4414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
#B
Provider Business Practice Location Address City Name:
MT. PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-884-8045
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HADER
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
APPOINTED OFFICIAL
Authorized Official Telephone Number:
843-284-4267

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  480 , 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: GP4434 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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