Provider Demographics
NPI:1508849837
Name:GEORGETOWN PHYSICIAN ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GEORGETOWN PHYSICIAN ASSOCIATES, LLC
Other - Org Name:TIDELANDS HEALTH FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-527-7102
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-520-8330
Mailing Address - Fax:843-652-8422
Practice Address - Street 1:1075 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2848
Practice Address - Country:US
Practice Address - Phone:843-546-5128
Practice Address - Fax:843-527-4027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDELANDS HEMINGWAY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-21
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6616 ANDREWSMedicaid
SCGP6617 HEMINGWAYMedicaid
SCGP6558 G'TOWNMedicaid
SCGP6616 ANDREWSMedicaid