Provider Demographics
NPI:1942394804
Name:HILTON HEAD GASTROENTEROLOGY, PA
Entity Type:Organization
Organization Name:HILTON HEAD GASTROENTEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GWOZDZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-681-6668
Mailing Address - Street 1:35 BILL FRIES DR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2730
Mailing Address - Country:US
Mailing Address - Phone:843-681-6668
Mailing Address - Fax:843-681-3295
Practice Address - Street 1:35 BILL FRIES DR
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-2730
Practice Address - Country:US
Practice Address - Phone:843-681-6668
Practice Address - Fax:843-681-3295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14617207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2995Medicaid
SCCH2897Medicare PIN
SCGP2995Medicaid
SC6832Medicare PIN