Basic Information
| Provider Information | |||||||||
| NPI: | 1013900125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WACCAMAW CARDIOLOGY PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2376 CYPRESS CIR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433478953 | ||||||||
| FaxNumber: | 8433470226 | ||||||||
| Practice Location | |||||||||
| Address1: | 2376 CYPRESS CIR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433478953 | ||||||||
| FaxNumber: | 8433470226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRESKO | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8433478953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GP3178 | 05 | SC | MEDICAID |