Provider Demographics
NPI:1972557494
Name:WACCAMAW KIDNEY & HYPERTENSION SPECIALISTS,P.A.
Entity Type:Organization
Organization Name:WACCAMAW KIDNEY & HYPERTENSION SPECIALISTS,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:COHN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-546-0223
Mailing Address - Street 1:PO BOX 2688
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-2688
Mailing Address - Country:US
Mailing Address - Phone:843-546-0223
Mailing Address - Fax:843-545-0024
Practice Address - Street 1:1052A HUGER DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3322
Practice Address - Country:US
Practice Address - Phone:843-546-0223
Practice Address - Fax:843-545-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13126207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC131262Medicaid
SC267918Medicaid
SCI03842Medicare UPIN
SC6312Medicare ID - Type Unspecified
SC267918Medicaid