1578623039 NPI number — GRAND STRAND GYNECOLOGY

Table of content: (NPI 1578623039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578623039 NPI number — GRAND STRAND GYNECOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND STRAND GYNECOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1578623039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4728 JENN DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29577-5714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-449-5553
Provider Business Mailing Address Fax Number:
843-449-4453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 MEDICAL CIR
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:
29572-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-5553
Provider Business Practice Location Address Fax Number:
843-449-4453
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-449-5553

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA4575 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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