Provider Demographics
NPI:1497735997
Name:PENINSULA ENT AND PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:PENINSULA ENT AND PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATAHSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GLENCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-958-8877
Mailing Address - Street 1:125 DOUGHTY ST
Mailing Address - Street 2:SUITE 440
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5736
Mailing Address - Country:US
Mailing Address - Phone:843-958-8877
Mailing Address - Fax:843-958-8878
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 440
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5736
Practice Address - Country:US
Practice Address - Phone:843-958-8877
Practice Address - Fax:843-958-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC128409Medicaid
SC128409Medicaid