1669188538 NPI number — SOUTHERN SHORES UROGYNECOLOGY AND PELVIC RECONSTRUCTIVE SURGERY PC

Table of content: (NPI 1669188538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669188538 NPI number — SOUTHERN SHORES UROGYNECOLOGY AND PELVIC RECONSTRUCTIVE SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN SHORES UROGYNECOLOGY AND PELVIC RECONSTRUCTIVE SURGERY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1669188538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 CIPRIANA DR STE 250
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:
29572-4621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 CIPRIANA DR STE 250
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:
29572-4621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-895-2120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS-HICKS
Authorized Official First Name:
JANET
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-895-2120

Provider Taxonomy Codes

  • Taxonomy code: 207VF0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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