MEDICARE: TIDELANDS HEALTH MARKET COMMON LLC

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	293D00000X	Physiological Laboratory
2	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1609437961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDELANDS HEALTH MARKET COMMON LLC

Provider Business Mailing Address
First Line	:	PO BOX 421718
Second Line	:
City	:	GEORGETOWN
State	:	SC
Zip	:	29442-4203
Country	:	US
Telephone Number	:	843-527-7000
Fax Number	:	843-848-5001

Provider Business Practice Location Address
First Line	:	2200 CROW LN STE 103
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-1663
Country	:	US
Telephone Number	:	843-848-5000
Fax Number	:	843-848-5001

Authorized Official
Title or Position	:	EVP & CFO
Name	:	ERIN BEADLE
Credential	:
Telephone Number	:	843-520-8617

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	04/16/2026

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