Provider Demographics
NPI:1972547289
Name:ST GEORGE MED CNTR PHCY
Entity type:Organization
Organization Name:ST GEORGE MED CNTR PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-531-6900
Mailing Address - Street 1:401 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:SC
Mailing Address - Zip Code:29477-2451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 RIDGE ST
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:SC
Practice Address - Zip Code:29477-2451
Practice Address - Country:US
Practice Address - Phone:843-636-9130
Practice Address - Fax:843-563-8229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50008540333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4226230OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SC785406Medicaid