Basic Information
| Provider Information | |||||||||
| NPI: | 1669412672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEWITT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | CARLISLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51030 | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295790018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432388660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432388660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4221 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 042215 | 05 | SC | MEDICAID |