Provider Demographics
NPI:1649239989
Name:WACCAMAW ONCOLOGY, PA
Entity Type:Organization
Organization Name:WACCAMAW ONCOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-545-7274
Mailing Address - Street 1:2405 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6410
Mailing Address - Country:US
Mailing Address - Phone:843-545-7274
Mailing Address - Fax:843-546-7353
Practice Address - Street 1:2405 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6410
Practice Address - Country:US
Practice Address - Phone:843-545-7274
Practice Address - Fax:843-546-7353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3475Medicaid
SCGP3475Medicaid