Provider Demographics
NPI:1679510416
Name:TRENT CANNON & RIDDICK ACKERMAN III
Entity Type:Organization
Organization Name:TRENT CANNON & RIDDICK ACKERMAN III
Other - Org Name:WALTERBORO OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:843-549-9568
Mailing Address - Street 1:400 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2710
Mailing Address - Country:US
Mailing Address - Phone:843-549-9568
Mailing Address - Fax:843-549-1530
Practice Address - Street 1:400 CONSTANCE ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2710
Practice Address - Country:US
Practice Address - Phone:843-549-9568
Practice Address - Fax:843-549-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0529Medicaid
SCGP0529Medicaid