Healthcare Provider Details

I. General information

NPI: 1609437961
Provider Name (Legal Business Name): TIDELANDS HEALTH MARKET COMMON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 CROW LN STE 103
MYRTLE BEACH SC
29577-1663
US

IV. Provider business mailing address

PO BOX 421718
GEORGETOWN SC
29442-4203
US

V. Phone/Fax

Practice location:
  • Phone: 843-848-5000
  • Fax: 843-848-5001
Mailing address:
  • Phone: 843-527-7000
  • Fax: 843-848-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ERIN BEADLE
Title or Position: EVP & CFO
Credential:
Phone: 843-520-8617