Provider Demographics
NPI:1710022660
Name:WACCAMAW SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:WACCAMAW SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LENTZ
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-546-7272
Mailing Address - Street 1:401 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2410
Mailing Address - Country:US
Mailing Address - Phone:843-546-7272
Mailing Address - Fax:843-546-0277
Practice Address - Street 1:401 MARINA DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2410
Practice Address - Country:US
Practice Address - Phone:843-546-7272
Practice Address - Fax:843-546-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC14277Medicaid
SCC880150Medicare UPIN
SC14277Medicaid