1093759755 NPI number — DR. JOAN M WISS MD

Table of content: DR. JOAN M WISS MD (NPI 1093759755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093759755 NPI number — DR. JOAN M WISS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISS
Provider First Name:
JOAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1093759755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29572-0021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-504-2121
Provider Business Mailing Address Fax Number:
843-487-0123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 2ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-796-7422
Provider Business Practice Location Address Fax Number:
877-817-3832
Provider Enumeration Date:
06/15/2006

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: 207N00000X , with the licence number:  18560 , 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: 185604 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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