Provider Demographics
NPI:1962795989
Name:BROAD RIVER PRIMARY CARE LLC
Entity type:Organization
Organization Name:BROAD RIVER PRIMARY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
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 741720
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1720
Mailing Address - Country:US
Mailing Address - Phone:843-682-7470
Mailing Address - Fax:843-682-2042
Practice Address - Street 1:35 BILL FRIES DR
Practice Address - Street 2:ISLAND MEDICAL PLAZA BUILDING A
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-2730
Practice Address - Country:US
Practice Address - Phone:843-682-7470
Practice Address - Fax:843-682-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DS4124Medicare PIN
GP5737Medicare PIN
A343Medicare PIN