Provider Demographics
NPI:1700992922
Name:WACCAMAW PAIN PARTNERS PA
Entity Type:Organization
Organization Name:WACCAMAW PAIN PARTNERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-669-5162
Mailing Address - Street 1:PO BOX 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0523
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-667-4573
Practice Address - Street 1:4033 HWY 17 BYPASS
Practice Address - Street 2:SUITE 108
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:27576
Practice Address - Country:US
Practice Address - Phone:843-669-5162
Practice Address - Fax:843-667-4573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC247512081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC247512Medicaid
SC=========OtherSTANDARD TAX ID
SC247512Medicaid
SCDE1719Medicare ID - Type UnspecifiedRAILROAD MEDICARE
SC8222Medicare PIN