MEDICARE: WACCAMAW UROLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	17277	SC
2	208800000X	Urology Physician	12505SC	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144305202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WACCAMAW UROLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	3911 HIGHWAY 17 STE A
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-5014
Country	:	US
Telephone Number	:	438-652-4000
Fax Number	:	843-652-4004

Provider Business Practice Location Address
First Line	:	3911A HIGHWAY 17
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-5014
Country	:	US
Telephone Number	:	438-652-4000
Fax Number	:	843-652-4004

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. THOMAS S CERASARO
Credential	:	MD
Telephone Number	:	842-833-3428

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	12/05/2024

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