Provider Demographics
NPI:1568659928
Name:LOWCOUNTRY UROLOGY CLINICS, PA
Entity Type:Organization
Organization Name:LOWCOUNTRY UROLOGY CLINICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APPOINTED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-284-4267
Mailing Address - Street 1:2687 LAKE PARK DR
Mailing Address - Street 2:LOWCOUNTRY UROLOGY CLINICS PA
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-725-4414
Mailing Address - Fax:
Practice Address - Street 1:125 DOUGHTY ST STE 680
Practice Address - Street 2:LOWCOUNTRY UROLOGY CLINICS PA
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5731
Practice Address - Country:US
Practice Address - Phone:843-577-6015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34655332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4437Medicaid
SC6015540007Medicare NSC
SC8519Medicare PIN