Healthcare Provider Details

I. General information

NPI: 1043707557
Provider Name (Legal Business Name): SEASIDE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 COLLEGE PARK RD # A
SUMMERVILLE SC
29486
US

IV. Provider business mailing address

1341 COLLEGE PARK RD # A
SUMMERVILLE SC
29486-8635
US

V. Phone/Fax

Practice location:
  • Phone: 843-400-0028
  • Fax: 843-790-8449
Mailing address:
  • Phone: 843-400-0028
  • Fax: 843-790-8449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number18442
License Number StateSC

VIII. Authorized Official

Name: AMANDA E. MCALLISTER
Title or Position: NP, OWNER
Credential: NP
Phone: 843-400-0028