Provider Demographics
NPI:1790813566
Name:SEACOAST PODIATRY ASSOCIATES PA
Entity Type:Organization
Organization Name:SEACOAST PODIATRY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KEEFER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-390-1333
Mailing Address - Street 1:3700 SAWTELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-7873
Mailing Address - Country:US
Mailing Address - Phone:843-390-1333
Mailing Address - Fax:843-390-1633
Practice Address - Street 1:3700 SAWTELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7873
Practice Address - Country:US
Practice Address - Phone:843-390-1333
Practice Address - Fax:843-390-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC546213ES0131X
SC539213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012THMedicaid
SCGP9943Medicaid
SC4304240001Medicare ID - Type UnspecifiedMEDICARE DURABLE MEDICAL
SC7114Medicare ID - Type UnspecifiedMEDICARE GROUP #