MEDICARE: SRP MEDICAL 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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1881485662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRP MEDICAL LLC

Provider Business Mailing Address
First Line	:	742 SAINT ANDREWS BLVD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-7169
Country	:	US
Telephone Number	:	407-516-3756
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 BLUEWATER WAY
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29414-7923
Country	:	US
Telephone Number	:	407-516-3756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SONYA R PUCKETT
Credential	:	APRN-AGACNP
Telephone Number	:	407-516-3756

Provider Enumeration Date	:	05/13/2025
Last Update Date	:	05/13/2025

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