Provider Demographics
NPI:1790086726
Name:ADVANTAGE HEALTHCARE OF CHARLESTON LLC
Entity Type:Organization
Organization Name:ADVANTAGE HEALTHCARE OF CHARLESTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-553-2211
Mailing Address - Street 1:122 S. GOOSE CREEK BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-0488
Mailing Address - Country:US
Mailing Address - Phone:843-553-2211
Mailing Address - Fax:843-553-2210
Practice Address - Street 1:122 S GOOSE CREEK BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3136
Practice Address - Country:US
Practice Address - Phone:843-553-2211
Practice Address - Fax:843-553-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28866208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA66739888OtherMEDICARE PTAN
SC1275572158Medicare PIN