Basic Information
| Provider Information | |||||||||
| NPI: | 1518371137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGETOWN PHYSICIAN ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TIDELANDS HEALTH SURGICAL SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 421718 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294424203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435208883 | ||||||||
| FaxNumber: | 8436528422 | ||||||||
| Practice Location | |||||||||
| Address1: | 4040 HIGHWAY 17 UNIT 104 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295765098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528390 | ||||||||
| FaxNumber: | 8436528399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2014 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | SUTHERLAND | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8435277102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GP6535 | 05 | SC | MEDICAID | GP8839 | 05 | SC | MEDICAID | GP9181 | 05 | SC | MEDICAID |