MEDICARE: COMPLETE CARE MEDICAL GROUP 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	207R00000X	Internal Medicine Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1982152906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPLETE CARE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	1413 HIGHWAY 17 S
Second Line	:	SUITE 1200
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6040
Country	:	US
Telephone Number	:	843-631-4656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1413 HIGHWAY 17 S
Second Line	:	SUITE 1200
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6040
Country	:	US
Telephone Number	:	843-631-4656
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MS. TINA J LESTER
Credential	:
Telephone Number	:	804-939-7037

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	09/19/2016

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