Provider Demographics
NPI:1972586394
Name:DR JOAN WYNN TAYLOR LLC
Entity Type:Organization
Organization Name:DR JOAN WYNN TAYLOR LLC
Other - Org Name:JOAN WYNN TAYLOR, M. D. GEN. MED. PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:843-216-0080
Mailing Address - Street 1:3070 N HIGHWAY 17
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9300
Mailing Address - Country:US
Mailing Address - Phone:843-216-0080
Mailing Address - Fax:843-216-0082
Practice Address - Street 1:3070 N HIGHWAY 17
Practice Address - Street 2:SUITE 200
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9300
Practice Address - Country:US
Practice Address - Phone:843-216-0080
Practice Address - Fax:843-216-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC12593207Q00000X
SC12593208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4112Medicaid
SCD05498Medicare UPIN
SC8356Medicare PIN
SCGP4112Medicaid