Provider Demographics
NPI:1043707557
Name:SEASIDE FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:SEASIDE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:843-400-0028
Mailing Address - Street 1:1341 COLLEGE PARK RD # A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8635
Mailing Address - Country:US
Mailing Address - Phone:843-400-0028
Mailing Address - Fax:843-790-8449
Practice Address - Street 1:1341 COLLEGE PARK RD # A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486
Practice Address - Country:US
Practice Address - Phone:843-400-0028
Practice Address - Fax:843-790-8449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363LF0000X
SC18442363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2488Medicaid