Provider Demographics
NPI:1790780096
Name:WOOLLEN, STEPHANIE B (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:B
Last Name:WOOLLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 OLD WACCAMAW DR
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-7278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GEORGETOWN COMMUNITY HOSPITAL
Practice Address - Street 2:606 BLACK RIVER ROAD
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-520-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042002207R00000X, 207RN0300X, 208M00000X
SC15566207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN06701Medicaid
GA000706428VMedicaid
SCN06701Medicaid
GAE39234Medicare UPIN
GA000706428VMedicaid