Basic Information
| Provider Information | |||||||||
| NPI: | 1629482435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGETOWN PHYSICIAN ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIDELANDS HEALTH ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421718 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294424203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435208883 | ||||||||
| FaxNumber: | 8436528422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 N FRASER ST | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435457274 | ||||||||
| FaxNumber: | 8435458315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | SUTHERLAND | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8435277102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | GP7345 | 05 | SC | MEDICAID | GP6530 | 05 | SC | MEDICAID |