Provider Demographics
NPI:1093139420
Name:GEORGETOWN PHYSICIAN ASSOCIATES
Entity Type:Organization
Organization Name:GEORGETOWN PHYSICIAN ASSOCIATES
Other - Org Name:TIDELANDS HEALTH GASTROENTEROLOGY
Other - Org Type:Doing Business As
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 1:1011 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-527-3428
Practice Address - Fax:843-546-8216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8837Medicaid
SCGP6485Medicaid
SCGP8109Medicaid