Provider Demographics
NPI:1073652137
Name:WILLIAMSBURG MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:WILLIAMSBURG MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:V
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER ASSIS
Authorized Official - Phone:843-355-7461
Mailing Address - Street 1:500 THURGOOD MARSHALL BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556
Mailing Address - Country:US
Mailing Address - Phone:843-355-7461
Mailing Address - Fax:843-355-3616
Practice Address - Street 1:500 THURGOOD MARSHALL BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556
Practice Address - Country:US
Practice Address - Phone:843-355-7461
Practice Address - Fax:843-355-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5526208D00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA7215Medicaid
SC428935OtherRURAL HEALTH MEDICARE
SC055264Medicaid
TN428935OtherRURAL HEALTH MEDICARE
SCRHC103OtherRURAL HEALTH MEDICAID
SC428935OtherRURAL HEALTH MEDICARE
SCPA7215Medicaid