=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568659928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOWCOUNTRY UROLOGY CLINICS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 04/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 DOUGHTY ST STE 680 LOWCOUNTRY UROLOGY CLINICS PA
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29403-5731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-577-6015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2687 LAKE PARK DR LOWCOUNTRY UROLOGY CLINICS PA
-----------------------------------------------------
City | N CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-725-4414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APPOINTED OFFICIAL
-----------------------------------------------------
Name | DIANE S HADER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-284-4267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 34655
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------