=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487765897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY MICROSURGICAL UNIT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 HIGHMARKET ST STE 100
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29440-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-546-8421
-----------------------------------------------------
Fax | 843-546-1173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2900
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29442-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-546-8421
-----------------------------------------------------
Fax | 843-546-1173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GERALD E TILLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 843-546-8421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | ASF090
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------