Provider Demographics
NPI:1275528168
Name:MT. PLEASANT INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MT. PLEASANT INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARY NELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-881-1671
Mailing Address - Street 1:498 WANDO PARK BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7963
Mailing Address - Country:US
Mailing Address - Phone:843-881-1671
Mailing Address - Fax:866-834-5680
Practice Address - Street 1:498 WANDO PARK BLVD STE 500
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7963
Practice Address - Country:US
Practice Address - Phone:843-881-1671
Practice Address - Fax:866-834-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3336Medicaid
7189Medicare PIN
CJ9503Medicare PIN