Provider Demographics
NPI:1114322336
Name:SUNGATE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SUNGATE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-842-2020
Mailing Address - Street 1:10 WILLIAM POPE DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7549
Mailing Address - Country:US
Mailing Address - Phone:843-842-2020
Mailing Address - Fax:843-705-1512
Practice Address - Street 1:10 WILLIAM POPE DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7549
Practice Address - Country:US
Practice Address - Phone:843-842-2020
Practice Address - Fax:843-705-1512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207W00000X, 207Y00000X, 231H00000X
SC985207Q00000X
SC16864207W00000X
SC37644208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty