Healthcare Provider Details

I. General information

NPI: 1548213564
Provider Name (Legal Business Name): WACCAMAW GASTROENTEROLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N FRASER ST
GEORGETOWN SC
29440-2848
US

IV. Provider business mailing address

1011 N FRASER ST
GEORGETOWN SC
29440-2848
US

V. Phone/Fax

Practice location:
  • Phone: 843-527-3428
  • Fax: 843-546-8216
Mailing address:
  • Phone: 843-527-3428
  • Fax: 843-546-8216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURENCE HAVENS BALLOU
Title or Position: PARTNER
Credential: MD
Phone: 843-527-3428