Provider Demographics
NPI:1518368307
Name:BROAD RIVER PRIMARY CARE LLC
Entity Type:Organization
Organization Name:BROAD RIVER PRIMARY CARE LLC
Other - Org Name:INFECTIOUS DISEASE ASSOCIATES OF THE LOW COUNTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 741720
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1720
Mailing Address - Country:US
Mailing Address - Phone:843-682-1064
Mailing Address - Fax:843-682-1063
Practice Address - Street 1:25 HOSPITAL CENTER BLVD
Practice Address - Street 2:SUITE 303A
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-2738
Practice Address - Country:US
Practice Address - Phone:843-682-1064
Practice Address - Fax:843-682-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty