Healthcare Provider Details

I. General information

NPI: 1114953742
Provider Name (Legal Business Name): SOUTHEAST WOUND SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9302 MEDIAL PLAZA DRIVE SUITE A
CHARLESTON SC
29406-9142
US

IV. Provider business mailing address

PO BOX 1345
SAVANNAH GA
31402-1345
US

V. Phone/Fax

Practice location:
  • Phone: 912-232-9700
  • Fax: 912-748-0270
Mailing address:
  • Phone: 912-232-9700
  • Fax: 912-748-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J. GREGORY
Title or Position: OWNER
Credential: M.D.
Phone: 912-232-9700