MEDICARE: TIDEWATER NEUROLOGY

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	174400000X	Specialist	19697	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	:	1962454124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER NEUROLOGY

Provider Business Mailing Address
First Line	:	913 B BOWMAN RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-3235
Country	:	US
Telephone Number	:	843-856-9530
Fax Number	:	843-971-1345

Provider Business Practice Location Address
First Line	:	913 B BOWMAN RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-3235
Country	:	US
Telephone Number	:	843-856-9530
Fax Number	:	843-971-1345

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS SANDERS HUGHES
Credential	:	MD
Telephone Number	:	843-856-9530

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	11/30/2007

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Directions to “TIDEWATER NEUROLOGY ” Practice Location

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