Provider Demographics
NPI:1083275366
Name:TIDELANDS AND MEDQUEST JOINT VENTURE, LLC
Entity Type:Organization
Organization Name:TIDELANDS AND MEDQUEST JOINT VENTURE, LLC
Other - Org Name:TIDELANDS HEALTH IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-527-7102
Mailing Address - Street 1:606 BLACK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3304
Mailing Address - Country:US
Mailing Address - Phone:843-527-7000
Mailing Address - Fax:843-652-8032
Practice Address - Street 1:900 21ST AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7483
Practice Address - Country:US
Practice Address - Phone:843-916-1700
Practice Address - Fax:843-916-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology