Provider Demographics
NPI: | 1548505506 |
---|---|
Name: | GEORGETOWN PHYSICIAN ASSOCIATES, LLC |
Entity type: | Organization |
Organization Name: | GEORGETOWN PHYSICIAN ASSOCIATES, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EVP & CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ELIZABETH |
Authorized Official - Middle Name: | SUTHERLAND |
Authorized Official - Last Name: | WARD |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 843-527-7102 |
Mailing Address - Street 1: | PO BOX 421718 |
Mailing Address - Street 2: | |
Mailing Address - City: | GEORGETOWN |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29442-4203 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-520-8883 |
Mailing Address - Fax: | 843-652-8422 |
Practice Address - Street 1: | 4301 DICK POND RD |
Practice Address - Street 2: | |
Practice Address - City: | MYRTLE BEACH |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29588 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-652-8108 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | GEORGETOWN PHYSICIAN SERVICES, LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2012-12-03 |
Last Update Date: | 2020-05-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty |