NPIMap

Organization Active NPI

Tidewater Doctors LLC

  • Family Medicine Physician
  • Charleston, SC
National Provider Identifier
1992474654
Registry record updated Sep 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
TIDEWATER DOCTORS LLC
Practice address
2270 Ashley Crossing Dr Ste 150
Charleston, SC 29414-5702
Phone
(843) 766-1936
Fax
(843) 766-1206
NPI assigned
Sep 7, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 7, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andrea Hurley
Title
Practice Administrator
Phone
(843) 200-7721

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X

Addresses

Primary practice location

2270 Ashley Crossing Dr Ste 150
Charleston, SC 29414-5702

Mailing address

2834 Aquaduct St
Charleston, SC 29414-7410
Phone (843) 200-7721

Other practice location 1

2270 Ashley Crossing Dr Ste 155
Charleston, SC 29414-5749
Phone (843) 990-5866

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211109001955 SC Part B Supplier - Clinic/Group Practice 2466841655 Receives reassigned benefits from 3 practitioners
2 other NPIs on this enrollment
Practice locations: Charleston, SC

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Tidewater Doctors LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1630972800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1630972800000",
    "number": "1992474654",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2834 AQUADUCT ST",
            "city": "CHARLESTON",
            "state": "SC",
            "postal_code": "294147410",
            "telephone_number": "843-200-7721"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2270 ASHLEY CROSSING DR STE 150",
            "city": "CHARLESTON",
            "state": "SC",
            "postal_code": "294145702",
            "telephone_number": "843-766-1936",
            "fax_number": "843-766-1206"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2270 Ashley Crossing Dr Ste 155",
            "address_purpose": "LOCATION",
            "city": "Charleston",
            "state": "SC",
            "postal_code": "294145749",
            "country_code": "US",
            "telephone_number": "843-990-5866",
            "fax_number": "843-868-8041",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TIDEWATER DOCTORS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-09-07",
        "last_updated": "2021-09-07",
        "certification_date": "2021-09-07",
        "status": "A",
        "authorized_official_last_name": "HURLEY",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "843-200-7721"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charleston, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.