Healthcare Provider Details

I. General information

NPI: 1821769290
Provider Name (Legal Business Name): TIDEWATER DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 ASHLEY CROSSING DR STE 155
CHARLESTON SC
29414-5749
US

IV. Provider business mailing address

2834 AQUADUCT ST
CHARLESTON SC
29414-7410
US

V. Phone/Fax

Practice location:
  • Phone: 843-990-5866
  • Fax: 843-868-8041
Mailing address:
  • Phone: 843-200-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA HURLEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 843-200-7721