Healthcare Provider Details

I. General information

NPI: 1437566510
Provider Name (Legal Business Name): TIDES GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 E SHIPYARD RD
MT PLEASANT SC
29464-2677
US

IV. Provider business mailing address

159 E SHIPYARD RD
MT PLEASANT SC
29464-2677
US

V. Phone/Fax

Practice location:
  • Phone: 843-743-4241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JEFFREY DOROCIAK
Title or Position: PRESIDENT
Credential:
Phone: 843-743-4241