Healthcare Provider Details

I. General information

NPI: 1962454124
Provider Name (Legal Business Name): TIDEWATER NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 B BOWMAN RD
MT PLEASANT SC
29464-3235
US

IV. Provider business mailing address

913 B BOWMAN RD
MT PLEASANT SC
29464-3235
US

V. Phone/Fax

Practice location:
  • Phone: 843-856-9530
  • Fax: 843-971-1345
Mailing address:
  • Phone: 843-856-9530
  • Fax: 843-971-1345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19697
License Number StateSC

VIII. Authorized Official

Name: THOMAS SANDERS HUGHES
Title or Position: OWNER
Credential: MD
Phone: 843-856-9530