=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962603134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILTON HEAD GASTROENTEROLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 11/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 BILL FRIES DR BLDG F
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-681-6630
-----------------------------------------------------
Fax | 843-681-3295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 NEW RIVER PKWY BLDG 6 SUITE 11
-----------------------------------------------------
City | HARDEEVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29927-4450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-208-3400
-----------------------------------------------------
Fax | 843-681-3295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | SHAUNA DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-681-6630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------