Healthcare Provider Details

I. General information

NPI: 1528702214
Provider Name (Legal Business Name): THOMAS GRAHAM LOVETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

3425 HOBSON DR
JOHNS ISLAND SC
29455-8137
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7111
  • Fax:
Mailing address:
  • Phone: 843-729-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number240022
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26135
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: