Provider Demographics
NPI:1992276091
Name:PREMIER MEDICAL OF SC LLC
Entity type:Organization
Organization Name:PREMIER MEDICAL OF SC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-225-2374
Mailing Address - Street 1:354 FOLLY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2594
Mailing Address - Country:US
Mailing Address - Phone:843-225-2374
Mailing Address - Fax:
Practice Address - Street 1:5880 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6053
Practice Address - Country:US
Practice Address - Phone:843-225-2374
Practice Address - Fax:843-459-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9928Medicaid
SCPG0752Medicaid