Provider Demographics
NPI:1275720310
Name:LOWCOUNTRY UROLOGY CLINICS, PA
Entity Type:Organization
Organization Name:LOWCOUNTRY UROLOGY CLINICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APPOINTED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-284-4267
Mailing Address - Street 1:2687 LAKE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:N. CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-725-4414
Mailing Address - Fax:
Practice Address - Street 1:9231 MEDICAL PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:N. CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9101
Practice Address - Country:US
Practice Address - Phone:843-725-4414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOWCOUNTRY UROLOGY CLINICS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-03
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2006-01903NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4437Medicaid
SC6015540010Medicare NSC
SC8519Medicare PIN