Provider Demographics
NPI:1528274891
Name:MID-ISLAND PRIMARY AND URGENT CARE, LLC
Entity type:Organization
Organization Name:MID-ISLAND PRIMARY AND URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 100208
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0208
Mailing Address - Country:US
Mailing Address - Phone:843-681-2074
Mailing Address - Fax:
Practice Address - Street 1:58 SHELTER COVE LN
Practice Address - Street 2:STE L
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-3571
Practice Address - Country:US
Practice Address - Phone:843-681-2074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH CAROLINA HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8845OtherMEDICARE PTAN
SCGP4951Medicaid
SCDH1726Medicare PIN