Provider Demographics
NPI:1851557227
Name:LOWCOUNTRY UROLOGY CLINICS, PA
Entity Type:Organization
Organization Name:LOWCOUNTRY UROLOGY CLINICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-284-4267
Mailing Address - Street 1:2687 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-725-4414
Mailing Address - Fax:843-725-3118
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 770
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5736
Practice Address - Country:US
Practice Address - Phone:843-577-6015
Practice Address - Fax:843-727-2972
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOWCOUNTRY UROLOGY CLINICS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-05
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4434Medicaid
SCGP4434Medicaid