Basic Information
| Provider Information | |||||||||
| NPI: | 1609245737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARDEEVILLE MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ISLAND PODIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405479 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437058888 | ||||||||
| FaxNumber: | 8437057024 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 CELADON DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299072695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437058888 | ||||||||
| FaxNumber: | 8437057024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | JAMES | ||||||||
| AuthorizedOfficialFirstName: | WESLEY | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CFO, TENET | ||||||||
| AuthorizedOfficialTelephone: | 4042655009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.