Provider Demographics
NPI:1750474128
Name:AMSOL PHYSICIANS OF WALTERBORO SC LLC
Entity Type:Organization
Organization Name:AMSOL PHYSICIANS OF WALTERBORO SC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:843-549-2000
Mailing Address - Street 1:501 ROBERTSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2787
Mailing Address - Country:US
Mailing Address - Phone:843-549-2000
Mailing Address - Fax:
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-549-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDC4043OtherRR MEDICARE
SCGP4035Medicaid
SCGP4035Medicaid
SC=========OtherTRICARE
SC8114Medicare PIN