Provider Demographics
NPI:1669441481
Name:CAROLINA INTERNAL MEDICINE OF CONWAY, LLC
Entity Type:Organization
Organization Name:CAROLINA INTERNAL MEDICINE OF CONWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-349-1001
Mailing Address - Street 1:2367B CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8921
Mailing Address - Country:US
Mailing Address - Phone:843-349-1001
Mailing Address - Fax:843-349-1008
Practice Address - Street 1:2367B CYPRESS CIR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8921
Practice Address - Country:US
Practice Address - Phone:843-349-1001
Practice Address - Fax:843-349-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7402Medicare ID - Type UnspecifiedPROVIDER NUMBER