Basic Information
Provider Information | |||||||||
NPI: | 1205832193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDEN | ||||||||
FirstName: | THADDEUS | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3439 | ||||||||
Address2: |   | ||||||||
City: | NORTH MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295820439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438394447 | ||||||||
FaxNumber: | 8433990123 | ||||||||
Practice Location | |||||||||
Address1: | 906 MEDICAL CIR | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295724114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434975929 | ||||||||
FaxNumber: | 8438391037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2005 | ||||||||
LastUpdateDate: | 11/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 24030 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | 24030 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 24030 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 24030 | SC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | T83433 | 05 | SC |   | MEDICAID |