Healthcare Provider Details

I. General information

NPI: 1649008087
Provider Name (Legal Business Name): QUEENS RHEUMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORPORATE PKWY STE 106 SUITE 106
FORT MILL SC
29707-4526
US

IV. Provider business mailing address

1040 EDGEWATER CORPORATE PKWY STE 106
FORT MILL SC
29707-4526
US

V. Phone/Fax

Practice location:
  • Phone: 803-913-4500
  • Fax: 803-913-4600
Mailing address:
  • Phone: 803-913-4500
  • Fax: 803-913-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE TERESA GEORGE
Title or Position: MD
Credential:
Phone: 803-913-4500