Basic Information
Provider Information | |||||||||
NPI: | 1790813566 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEACOAST PODIATRY ASSOCIATES PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3700 SAWTELL RD | ||||||||
Address2: |   | ||||||||
City: | LITTLE RIVER | ||||||||
State: | SC | ||||||||
PostalCode: | 295667873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433901333 | ||||||||
FaxNumber: | 8433901633 | ||||||||
Practice Location | |||||||||
Address1: | 3700 SAWTELL RD | ||||||||
Address2: |   | ||||||||
City: | LITTLE RIVER | ||||||||
State: | SC | ||||||||
PostalCode: | 295667873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433901333 | ||||||||
FaxNumber: | 8433901633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2007 | ||||||||
LastUpdateDate: | 11/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KEEFER | ||||||||
AuthorizedOfficialFirstName: | BRADLEY | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 8433901333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 546 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0131X | 539 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
ID | Type | State | Issuer | Description | 89012TH | 05 | NC |   | MEDICAID | GP9943 | 05 | SC |   | MEDICAID |