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164 Waccamaw Medical Park Dr Conway SC 29526-8903 | |
| (843) 347-5060 | |
| (843) 347-3959 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 164 Waccamaw Medical Park Dr, Conway, South Carolina |
| Authorized Official Name and Position | Tracy L Turner (CONTROLLER) |
| Authorized Official Contact | 8038988503 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
164 Waccamaw Medical Park Dr Conway SC 29526-8903 Ph: (843) 347-5060 | 164 Waccamaw Medical Park Dr Conway SC 29526-8903 Ph: (843) 347-5060 |
| NPI Number | 1356397228 |
|---|---|
| Provider Enumeration Date | 05/25/2006 |
| Last Update Date | 09/20/2019 |
| Medicare PECOS PAC ID | 9032021175 |
|---|---|
| Medicare Enrollment ID | O20040303000705 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1356397228 | NPI | - | NPPES |
| 327877 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Violetta Dorota Czepowicz |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1356325435 PECOS PAC ID: 1254239338 Enrollment ID: I20031229000172 |
| Provider Name | Robert Hotchkiss |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1497843882 PECOS PAC ID: 4688565542 Enrollment ID: I20040322001108 |
| Provider Name | Shalini Mittal |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1538198676 PECOS PAC ID: 7517942048 Enrollment ID: I20040621000312 |
| Provider Name | Janice C Reynolds |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1699723106 PECOS PAC ID: 4082664677 Enrollment ID: I20050201000301 |
| Provider Name | Sally S Blake |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750432985 PECOS PAC ID: 3779529458 Enrollment ID: I20050705000156 |
| Provider Name | Rupa Shetty |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1962428235 PECOS PAC ID: 8022064989 Enrollment ID: I20051130000256 |
| Provider Name | Ayanna Swinton Jamison |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1053359851 PECOS PAC ID: 2163445735 Enrollment ID: I20060110000298 |
| Provider Name | Nancy Elizabeth Hoevenaar |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1376576447 PECOS PAC ID: 6901819242 Enrollment ID: I20060803000116 |
| Provider Name | Valerie M Mosley |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1992896559 PECOS PAC ID: 5698772606 Enrollment ID: I20061106000335 |
| Provider Name | Melanie Taylor Hatzis |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1154424398 PECOS PAC ID: 0345343695 Enrollment ID: I20070307000427 |
| Provider Name | Melinda E Edwards |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1245252774 PECOS PAC ID: 1254435027 Enrollment ID: I20070404000108 |
| Provider Name | Kathleen A O Leary |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1366521684 PECOS PAC ID: 5991765083 Enrollment ID: I20080513000446 |
| Provider Name | Chioma R Ekechukwu |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1376650275 PECOS PAC ID: 4587735410 Enrollment ID: I20080619000389 |
| Provider Name | Michael K Smith |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1154490084 PECOS PAC ID: 4587727946 Enrollment ID: I20090112000055 |
| Provider Name | Pravina Sheth |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1700810561 PECOS PAC ID: 5799848750 Enrollment ID: I20090116000499 |
| Provider Name | Hossan A Hassan |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1346226453 PECOS PAC ID: 4688727340 Enrollment ID: I20090729000258 |
| Provider Name | John Pybass |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1891913455 PECOS PAC ID: 3577695733 Enrollment ID: I20100723000229 |
| Provider Name | Stephen J Enns |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1487711354 PECOS PAC ID: 1759450158 Enrollment ID: I20100827000729 |
| Provider Name | Roxie D Bosier |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588966527 PECOS PAC ID: 2961688718 Enrollment ID: I20110512000543 |
| Provider Name | Christian F Reusche |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1932306545 PECOS PAC ID: 3678742244 Enrollment ID: I20110816000705 |
| Provider Name | John V Custer |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1578679452 PECOS PAC ID: 3476727140 Enrollment ID: I20111114000872 |
| Provider Name | Margaret E Rittenbury |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1700833274 PECOS PAC ID: 6204002983 Enrollment ID: I20111230000028 |
| Provider Name | Philip Sinato |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1053518621 PECOS PAC ID: 9436318821 Enrollment ID: I20120303000035 |
| Provider Name | Kontasha Shamika Wise |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1679850044 PECOS PAC ID: 5395906960 Enrollment ID: I20120409000685 |
| Provider Name | Gregory E Smith |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1023063377 PECOS PAC ID: 3779570957 Enrollment ID: I20120410000672 |
| Provider Name | Lori Gerding |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1801834726 PECOS PAC ID: 3678592441 Enrollment ID: I20120411000833 |
| Provider Name | Amr Abdelghany Khalafallah |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1013018308 PECOS PAC ID: 4082685136 Enrollment ID: I20120627000499 |
| Provider Name | Daniel J Uderitz |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1295963437 PECOS PAC ID: 1658528815 Enrollment ID: I20120823000718 |
| Provider Name | Kristi L West |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245273663 PECOS PAC ID: 6305080425 Enrollment ID: I20130911000540 |
| Provider Name | Jon Kennon Peters |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1720320740 PECOS PAC ID: 2860626470 Enrollment ID: I20131015001627 |
| Provider Name | Kurt Klauburg |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1659370021 PECOS PAC ID: 2163458738 Enrollment ID: I20140221001436 |
| Provider Name | Tammy A Hightower |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1144245739 PECOS PAC ID: 6204066830 Enrollment ID: I20140227001453 |
| Provider Name | Mildred L Martin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1942267703 PECOS PAC ID: 1052543071 Enrollment ID: I20140407000219 |
| Provider Name | Tamara L Smith |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1295802304 PECOS PAC ID: 0840412581 Enrollment ID: I20141112001369 |
| Provider Name | Daniel John Balog |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1710036470 PECOS PAC ID: 4688998263 Enrollment ID: I20150130002282 |
| Provider Name | Gretchen Enright |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1043393051 PECOS PAC ID: 8022311927 Enrollment ID: I20160127001600 |
| Provider Name | Khoa Dang Tran |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1346458908 PECOS PAC ID: 8628977675 Enrollment ID: I20160127002348 |
| Provider Name | Martha G Smith |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1790822450 PECOS PAC ID: 4880587328 Enrollment ID: I20160225001846 |
| Provider Name | Stephanie L Price |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1487948774 PECOS PAC ID: 7113163601 Enrollment ID: I20160815001282 |
| Provider Name | Meenakshi Parmar |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1417170143 PECOS PAC ID: 6709953417 Enrollment ID: I20161205001740 |
| Provider Name | Judy G Figueroa |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1669657987 PECOS PAC ID: 8921180217 Enrollment ID: I20170926002594 |
| Provider Name | Tecora A Williams |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1598030868 PECOS PAC ID: 9830458256 Enrollment ID: I20180110002505 |
| Provider Name | Shadi Duchesne |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1720208010 PECOS PAC ID: 7214964022 Enrollment ID: I20180212002557 |
| Provider Name | Rhonda Michelle Cartee |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1730159864 PECOS PAC ID: 7618930553 Enrollment ID: I20190123000175 |
| Provider Name | Patrick Wiita |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1841558772 PECOS PAC ID: 8921341017 Enrollment ID: I20190513000597 |
| Provider Name | Ebele Catherine Compean |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1033591979 PECOS PAC ID: 4587953286 Enrollment ID: I20190925001330 |
| Provider Name | Jared Joshua Carbone |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164810610 PECOS PAC ID: 9638400245 Enrollment ID: I20191014000873 |
| Provider Name | Elizabeth Ann Holloway Jensen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1548230220 PECOS PAC ID: 8820421753 Enrollment ID: I20191209000422 |
| Provider Name | Shalika W Guram |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1174904346 PECOS PAC ID: 9638468390 Enrollment ID: I20200206000573 |
| Provider Name | Winston E Dill |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1134180243 PECOS PAC ID: 6608768544 Enrollment ID: I20200527000364 |
| Provider Name | Kevin Gormley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962567552 PECOS PAC ID: 9931467123 Enrollment ID: I20200918001577 |
| Provider Name | Keisha Sharie Yarborough |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1982229464 PECOS PAC ID: 3173942570 Enrollment ID: I20201005002092 |
| Provider Name | Derenda Beasley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1386120343 PECOS PAC ID: 3072934512 Enrollment ID: I20210208000174 |
| Provider Name | Tongii Shavers |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1962594481 PECOS PAC ID: 6608820261 Enrollment ID: I20210624003214 |
| Provider Name | Ogechi Lebeanya |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316537285 PECOS PAC ID: 7416341318 Enrollment ID: I20220217002769 |
| Provider Name | Rekha S Prasad |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1164480745 PECOS PAC ID: 1658353396 Enrollment ID: I20220614002517 |
| Provider Name | Nitin M Kamble |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1811214737 PECOS PAC ID: 9436456142 Enrollment ID: I20221230000542 |
| Provider Name | Murtuza Vali |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1366515009 PECOS PAC ID: 1658427422 Enrollment ID: I20230306002167 |
| Provider Name | Walter Schmalstieg |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1740209683 PECOS PAC ID: 7618016262 Enrollment ID: I20230727000991 |
| Provider Name | Kimberly Latashia Walker |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1861197337 PECOS PAC ID: 1052775954 Enrollment ID: I20230911003941 |
| Provider Name | Lyntressa Danielle Grant |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083955793 PECOS PAC ID: 3375784911 Enrollment ID: I20240416002566 |
| Provider Name | Daniel Robert Lindsey |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1982183190 PECOS PAC ID: 9537592662 Enrollment ID: I20240805003184 |
| Provider Name | Kerrick Warren Breen |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1063078665 PECOS PAC ID: 3476092297 Enrollment ID: I20240826000214 |
| Provider Name | Abigail Long |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1518434034 PECOS PAC ID: 7810436656 Enrollment ID: I20240826001048 |
| Provider Name | Chance Nevitt |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1588790299 PECOS PAC ID: 7911446620 Enrollment ID: I20240826004029 |
| Provider Name | Chan Carman |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1982139424 PECOS PAC ID: 2466991617 Enrollment ID: I20240831000037 |
| Provider Name | Brooke Ekalla Mccarthy |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1619520434 PECOS PAC ID: 6002357084 Enrollment ID: I20240918000075 |
| Provider Name | Christina Danielle Turner |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1134747496 PECOS PAC ID: 7719428705 Enrollment ID: I20240918000152 |
| Provider Name | Fran Caroline Clark |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1629094479 PECOS PAC ID: 3072044056 Enrollment ID: I20241001002940 |
| Provider Name | Jamie Lee Barkdull |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1831862911 PECOS PAC ID: 1254864630 Enrollment ID: I20241023002840 |
| Provider Name | Peggy Aylssa Joann Brookshire |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1548955941 PECOS PAC ID: 7214460484 Enrollment ID: I20241025002403 |
| Provider Name | Cordy Mcgill-scarlett |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1790301240 PECOS PAC ID: 2062831001 Enrollment ID: I20241104003145 |
| Provider Name | Leslie Mathewson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1376588236 PECOS PAC ID: 9133179476 Enrollment ID: I20241123000195 |
| Provider Name | Venita Catrice Randall |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1972784916 PECOS PAC ID: 8325573405 Enrollment ID: I20241126002978 |
Little River Medical Center, Inc. Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 164 Waccamaw Medical Park Dr, Conway, SC 29526 Phone: 843-347-4888 Fax: 843-663-1017 | |
Coastal Neuropsychiatry, Pa Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 132 Professional Park Dr, Suite B, Conway, SC 29526 Phone: 843-347-0356 Fax: 843-347-0390 | |
Waccamaw Center For Mental Health Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 164 Waccamaw Medical Park Dr, Conway, SC 29526 Phone: 843-347-4888 | |
Mario S. Bangco, Md, Pa Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 170 Waccamaw Medical Park Ct, Conway, SC 29526 Phone: 843-347-4473 Fax: 843-347-0290 | |
Sistas Of Encouragement Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 2405 Farmwood Cir, Conway, SC 29527 Phone: 843-999-5525 |