Provider Demographics
NPI:1255400958
Name:CREEKSIDE WOMEN'S CARE, PA
Entity type:Organization
Organization Name:CREEKSIDE WOMEN'S CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALYCIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-769-5620
Mailing Address - Street 1:2097 HENRY TECKLENBURG DR
Mailing Address - Street 2:SUITE 312-W
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5740
Mailing Address - Country:US
Mailing Address - Phone:843-769-5620
Mailing Address - Fax:843-769-5625
Practice Address - Street 1:2097 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 312-W
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5740
Practice Address - Country:US
Practice Address - Phone:843-769-5620
Practice Address - Fax:843-769-5625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC47-1592Medicaid
SC47-1592Medicaid