Healthcare Provider Details

I. General information

NPI: 1366786485
Provider Name (Legal Business Name): SUNGATE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WILLIAM POPE DRIVE SUNGATE MEDICAL CENTER
BLUFFTON SC
29909
US

IV. Provider business mailing address

10 WILLIAM POPE DRIVE SUNGATE MEDICAL CENTER
BLUFFTON SC
29909
US

V. Phone/Fax

Practice location:
  • Phone: 843-705-1510
  • Fax: 843-705-1511
Mailing address:
  • Phone: 843-705-1510
  • Fax: 843-705-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO 985
License Number StateSC

VIII. Authorized Official

Name: DR. KENNETH DANIEL FARR
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 843-842-2020