1073852067 NPI number — DOCTORS CARE SC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073852067 NPI number — DOCTORS CARE SC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS CARE SC, PA
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:
DOCTORS CARE STRAND MEDICAL
Provider Other Organization Name Type Code:
3
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:
1073852067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 HENDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-758-2600
Provider Business Mailing Address Fax Number:
803-253-8896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 21ST 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:
29577-7402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-626-9379
Provider Business Practice Location Address Fax Number:
843-448-0707
Provider Enumeration Date:
02/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JANSSEN
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
803-782-4278

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP0890 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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