Basic Information
| Provider Information | |||||||||
| NPI: | 1033169156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOWCOUNTRY MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLANTATION PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1871 SAVAGE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1871 SAVAGE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666308 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8439378101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | SC | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208000000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP1199 | 05 | SC | MEDICAID | DE2219 | 05 | SC | MEDICAID |