Provider Demographics
NPI:1922047943
Name:COLLETON NEUROLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:COLLETON NEUROLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-549-0795
Mailing Address - Street 1:302 MEDICAL PARK DR
Mailing Address - Street 2:STE 210
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5747
Mailing Address - Country:US
Mailing Address - Phone:843-549-0795
Mailing Address - Fax:843-542-2920
Practice Address - Street 1:302 MEDICAL PARK DR
Practice Address - Street 2:STE 210
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5747
Practice Address - Country:US
Practice Address - Phone:843-549-0795
Practice Address - Fax:843-542-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE8510Medicare PIN
SC8408Medicare PIN