Provider Demographics
NPI:1376033829
Name:CHARLESTON MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:CHARLESTON MEDICAL ASSOCIATES
Other - Org Name:GENERATIONS PEDIATRICS AND INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JUSTICE
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-614-7953
Mailing Address - Street 1:1483 TOBIAS GADSON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4795
Mailing Address - Country:US
Mailing Address - Phone:843-405-1110
Mailing Address - Fax:
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4795
Practice Address - Country:US
Practice Address - Phone:843-405-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC311442Medicaid