Provider Demographics
NPI:1144401365
Name:GEORGETOWN HEALTH GROUP
Entity Type:Organization
Organization Name:GEORGETOWN HEALTH GROUP
Other - Org Name:ANDREWS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-527-4442
Mailing Address - Street 1:1075 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2848
Mailing Address - Country:US
Mailing Address - Phone:843-527-4442
Mailing Address - Fax:843-527-4027
Practice Address - Street 1:701 S MORGAN AVE
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:SC
Practice Address - Zip Code:29510-2959
Practice Address - Country:US
Practice Address - Phone:843-264-5253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1366Medicaid
SCGP1366Medicaid