Provider Demographics
NPI:1568493849
Name:BIG FISH PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:BIG FISH PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-971-3373
Mailing Address - Street 1:3400 SALTERBECK CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7118
Mailing Address - Country:US
Mailing Address - Phone:843-971-3373
Mailing Address - Fax:
Practice Address - Street 1:3400 SALTERBECK CT
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7118
Practice Address - Country:US
Practice Address - Phone:843-971-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 15656261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain