Basic Information
| Provider Information | |||||||||
| NPI: | 1083668669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND STRAND REGIONAL MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GRAND STRAND MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 809 82ND PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MYRLTE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
| FaxNumber: | 8436921109 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 82ND PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MYRLTE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
| FaxNumber: | 8436921109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRACE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8436921105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 304727092 | 05 | MI | MEDICAID | 719553 | 05 | NY | MEDICAID | 80553900 | 05 | WI | MEDICAID | 003071967 | 05 | CT | MEDICAID | 017817909 | 05 | MO | MEDICAID | 05252828 | 05 | MS | MEDICAID | 0593830 | 05 | IA | MEDICAID | 40757340 | 05 | CO | MEDICAID | 4200853 | 05 | VA | MEDICAID | 4017285 | 01 | BLUE CROSS | OTHER | 420085 | 01 | HIGHMARK BLUE CROSS | OTHER | XHSP32315 | 05 | CA | MEDICAID | 166374000 | 01 | DEPT OF LABOR | OTHER | 1762610 | 05 | LA | MEDICAID | 3016375 | 05 | WA | MEDICAID | 347055 | 05 | SC | MEDICAID | 62601083 | 05 | NM | MEDICAID | 9810008000 | 05 | WV | MEDICAID | 0420085 | 05 | RI | MEDICAID | 177832601 | 05 | TX | MEDICAID | 200011400A | 05 | OK | MEDICAID | 911683400 | 05 | FL | MEDICAID | 0420085 | 05 | TN | MEDICAID | 10025074600 | 05 | NE | MEDICAID | 100375470A | 05 | IN | MEDICAID | 00877918X | 05 | GA | MEDICAID | 400323300 | 05 | MD | MEDICAID | 4200085 | 05 | NC | MEDICAID | 568652 | 05 | HI | MEDICAID | 7202482 | 05 | MA | MEDICAID | 0019712300002 | 05 | PA | MEDICAID | 1000036024 | 05 | DE | MEDICAID | 1600584 | 05 | KY | MEDICAID | 411996 | 05 | OH | MEDICAID | 421260 | 05 | NJ | MEDICAID | 431967000 | 05 | ME | MEDICAID |