Provider Demographics
NPI:1760481758
Name:WATERWAY FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:WATERWAY FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFFKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-756-5300
Mailing Address - Street 1:3439 CASEY ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-2903
Mailing Address - Country:US
Mailing Address - Phone:843-756-5300
Mailing Address - Fax:843-756-6059
Practice Address - Street 1:3600 SEA MOUNTAIN HWY.
Practice Address - Street 2:SUITE C
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7640
Practice Address - Country:US
Practice Address - Phone:843-399-4848
Practice Address - Fax:843-756-6059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1062Medicaid
NC890291HOtherNC MEDICAID
CM7718OtherRAILROAD MEDICARE
NC0291HOtherBCBS
SC4770Medicare PIN