Provider Demographics
NPI:1770884264
Name:DR. THOMAS C. EDEWAARD
Entity type:Organization
Organization Name:DR. THOMAS C. EDEWAARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDEWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-821-9300
Mailing Address - Street 1:705 OLD TROLLEY RD
Mailing Address - Street 2:STE A
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5212
Mailing Address - Country:US
Mailing Address - Phone:843-821-9300
Mailing Address - Fax:843-821-9300
Practice Address - Street 1:705 OLD TROLLEY RD
Practice Address - Street 2:STE A
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5212
Practice Address - Country:US
Practice Address - Phone:843-821-9300
Practice Address - Fax:843-821-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD09729Medicaid
SCD09729Medicaid
U348370281Medicare PIN
SC0958180001Medicare NSC