Provider Demographics
NPI:1821089434
Name:HILTON HEAD SPORTS MEDICINE
Entity Type:Organization
Organization Name:HILTON HEAD SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-689-9720
Mailing Address - Street 1:PO BOX 23613
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29925-3613
Mailing Address - Country:US
Mailing Address - Phone:843-689-9720
Mailing Address - Fax:843-689-9704
Practice Address - Street 1:22 BETHEA DR
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-4702
Practice Address - Country:US
Practice Address - Phone:843-689-9720
Practice Address - Fax:843-689-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16696207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2936Medicaid
SC6953OtherMEDICARE GROUP NUMBER
SCGP2936Medicaid