Healthcare Provider Details

I. General information

NPI: 1497062384
Provider Name (Legal Business Name): GEORGETOWN PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 N FRASER ST
GEORGETOWN SC
29440-2848
US

IV. Provider business mailing address

9699 OCEAN HWY
PAWLEYS ISLAND SC
29585-7425
US

V. Phone/Fax

Practice location:
  • Phone: 843-527-4442
  • Fax: 843-527-4027
Mailing address:
  • Phone: 843-237-4297
  • Fax: 843-237-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. SUE STARK
Title or Position: COADMINISTRATOR
Credential:
Phone: 843-543-0090