Provider Demographics
NPI:1972632115
Name:COLLETON HEART CENTER, LLC
Entity Type:Organization
Organization Name:COLLETON HEART CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-549-3400
Mailing Address - Street 1:415 ROBERTSON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5713
Mailing Address - Country:US
Mailing Address - Phone:843-549-3400
Mailing Address - Fax:843-549-1424
Practice Address - Street 1:415 ROBERTSON BLVD STE C
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5713
Practice Address - Country:US
Practice Address - Phone:843-549-3400
Practice Address - Fax:843-549-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21611207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1417940792OtherINDIVIDUAL NPI #
SC216117Medicaid
SCB43797Medicare ID - Type Unspecified