Provider Demographics
NPI:1598835639
Name:TIDEWATER SURGICAL GROUP, PA
Entity Type:Organization
Organization Name:TIDEWATER SURGICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRAOT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:VERONICA
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-797-8880
Mailing Address - Street 1:2831B TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-797-8880
Mailing Address - Fax:843-797-8884
Practice Address - Street 1:2831B TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9172
Practice Address - Country:US
Practice Address - Phone:843-797-8880
Practice Address - Fax:843-797-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCG93021208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4370Medicaid
SC8461Medicare ID - Type UnspecifiedDR SQUIRES MEDICARE #
SCG93021Medicare UPIN
SCGP4370Medicaid