Provider Demographics
NPI:1518371137
Name:GEORGETOWN PHYSICIAN ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GEORGETOWN PHYSICIAN ASSOCIATES, LLC
Other - Org Name:TIDELANDS HEALTH SURGICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SUTHERLAND
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:843-520-8883
Mailing Address - Fax:843-652-8422
Practice Address - Street 1:4040 HIGHWAY 17 UNIT 104
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5098
Practice Address - Country:US
Practice Address - Phone:843-652-8390
Practice Address - Fax:843-652-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6535Medicaid
SCGP8839Medicaid
SCGP9181Medicaid