Provider Demographics
NPI:1255603403
Name:INLET PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:INLET PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-652-5678
Mailing Address - Street 1:804 INLET SQUARE DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-7874
Mailing Address - Country:US
Mailing Address - Phone:843-652-5678
Mailing Address - Fax:843-652-5679
Practice Address - Street 1:804 INLET SQUARE DR UNIT B
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-7874
Practice Address - Country:US
Practice Address - Phone:843-652-5678
Practice Address - Fax:843-652-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30634207KA0200X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA843OtherMEDICARE PTAN
SC6687300001Medicare NSC