Provider Demographics
NPI:1023044245
Name:BOTELHO, TINA M (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BOTELHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:498 WANDO PARK BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7963
Mailing Address - Country:US
Mailing Address - Phone:843-606-9199
Mailing Address - Fax:843-718-2858
Practice Address - Street 1:498 WANDO PARK BLVD STE 500
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7963
Practice Address - Country:US
Practice Address - Phone:843-606-9199
Practice Address - Fax:843-718-2858
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC25344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571020809058OtherTRICARE SC
SCA913OtherTINA BOTELHO MD PTAN ASSOCIATED LEGACY INTERNAL MEDICINE LLC
SCP00202158OtherRR MEDICARE
SCP00802342OtherRR MEDICARE
SCAA8570A913OtherLEGACY INTERNAL MEDICINE LLC--GROUP PTAN
SC571020809012OtherBCBS SC
SC253442Medicaid
SCP00202158OtherRR MEDICARE
SC1881644987Medicare PIN
SC253442Medicaid
SCAA06016795Medicare PIN
SCA913OtherTINA BOTELHO MD PTAN ASSOCIATED LEGACY INTERNAL MEDICINE LLC
SCAA06013640Medicare PIN
SC1497874424Medicare PIN