Provider Demographics
NPI:1053612861
Name:TENET SOUTH CAROLINA ISLAND MEDICAL, LLC
Entity type:Organization
Organization Name:TENET SOUTH CAROLINA ISLAND MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 741439
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1439
Mailing Address - Country:US
Mailing Address - Phone:843-856-1771
Mailing Address - Fax:843-856-8788
Practice Address - Street 1:245 SEVEN FARMS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8500
Practice Address - Country:US
Practice Address - Phone:843-856-1771
Practice Address - Fax:843-856-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5667Medicaid
SCGP5667Medicaid
DR7073Medicare PIN