Basic Information
| Provider Information | |||||||||
| NPI: | 1346411923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOWCOUNTRY MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LMA ANCILLARY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 WINGO WAY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294641810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439378101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 SPRINGHALL DR | ||||||||
| Address2: | |||||||||
| City: | GOOSE CREEK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294455335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432662520 | ||||||||
| FaxNumber: | 8435534436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2008 | ||||||||
| LastUpdateDate: | 03/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8439378101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP2939 | 05 | SC | MEDICAID |