Basic Information
| Provider Information | |||||||||
| NPI: | 1225132665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCSWEENEY - TYSON | ||||||||
| FirstName: | DEIDRE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TYSON | ||||||||
| OtherFirstName: | DEIDRE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 WILLIAM H JOHNSON ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437775701 | ||||||||
| FaxNumber: | 8437777320 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WILLIAM H JOHNSON ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437775701 | ||||||||
| FaxNumber: | 8437777320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 83712 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | CA-G160210 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0101048009 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | 0101048009 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | CA-G160210 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | 83712 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 6720358 | 05 | VA | MEDICAID |