1942297635 NPI number — DR. GREGOR G CLEVELAND MD

Table of content: DR. GREGOR G CLEVELAND MD (NPI 1942297635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942297635 NPI number — DR. GREGOR G CLEVELAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEVELAND
Provider First Name:
GREGOR
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942297635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 AZALEA CT
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29577-5765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-692-0570
Provider Business Mailing Address Fax Number:
843-497-9566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 AZALEA CT
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-5765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-692-0570
Provider Business Practice Location Address Fax Number:
843-497-9566
Provider Enumeration Date:
09/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  15902 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05905 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 159027 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60773 . This is a "MEDCOST" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 154758900 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 154758900 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 300049800 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 570525838 . This is a "STANDARD TAX ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 890603R . This is a "MEDICAID OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".