Basic Information
Provider Information | |||||||||
NPI: | 1528482015 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GEORGETOWN PHYSICIAN ASSOCIATES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TIDELANDS HEALTH BREAST CENTER | ||||||||
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: | 4181 HIGHWAY 17 | ||||||||
Address2: |   | ||||||||
City: | MURRELLS INLET | ||||||||
State: | SC | ||||||||
PostalCode: | 29576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436513308 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2014 | ||||||||
LastUpdateDate: | 06/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARD | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | SUTHERLAND | ||||||||
AuthorizedOfficialTitleorPosition: | EVP & CFO | ||||||||
AuthorizedOfficialTelephone: | 8435277102 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | GP6476 | 05 | SC |   | MEDICAID |