Healthcare Provider Details

I. General information

NPI: 1649548132
Provider Name (Legal Business Name): WACCAMAW ONCOLOGY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 N FRASER ST
GEORGETOWN SC
29440-7764
US

IV. Provider business mailing address

2405 N FRASER ST PO BOX 1539
GEORGETOWN SC
29440-7764
US

V. Phone/Fax

Practice location:
  • Phone: 843-545-7274
  • Fax: 843-545-8315
Mailing address:
  • Phone: 843-545-7274
  • Fax: 843-545-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEANNE OWENS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 843-527-3428