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General NPI Number Information
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NPI Number | 1770510695
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Entity Type | Organization
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Legal Business Name | TIDEWATER INTERNAL MEDICINE, LLC
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 10/04/2007
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Provider Practice Location Address
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Address Line | 2097 HENRY TECKLENBURG DR SUITE 220
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City | CHARLESTON
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State | SC
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Zip | 29414-5740
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Country | US
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Telephone | 843-571-6868
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Fax | 843-571-6198
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Provider Business Mailing Address
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Address Line | 2097 HENRY TECKLENBURG DR SUITE 220
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City | CHARLESTON
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State | SC
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Zip | 29414-5740
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Country | US
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Telephone | 843-571-6868
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Fax | 843-571-6198
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. LAURA LEE KINNEY
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Credential | M.D.
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Telephone | 843-571-6868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 19466
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License Number State | SC
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