Provider Demographics
NPI:1770552408
Name:ADVANCED MEDICAL ASSOCIATES OF BEAUFORT, PC
Entity type:Organization
Organization Name:ADVANCED MEDICAL ASSOCIATES OF BEAUFORT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LONSCAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-986-9292
Mailing Address - Street 1:860 PARRIS ISLAND GTWY
Mailing Address - Street 2:SUITE B2
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-6921
Mailing Address - Country:US
Mailing Address - Phone:843-986-9292
Mailing Address - Fax:843-524-9294
Practice Address - Street 1:860 PARRIS ISLAND GTWY
Practice Address - Street 2:SUITE B-2
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-6921
Practice Address - Country:US
Practice Address - Phone:843-986-9292
Practice Address - Fax:843-524-9294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2493111N00000X
SC11027207Y00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH517Medicaid
SC6395990001Medicare NSC
SC8188Medicare PIN