Basic Information
| Provider Information | |||||||||
| NPI: | 1134238371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNABB | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 805 N 2ND ST | ||||||||
| Address2: | APT 4 | ||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705107227 | ||||||||
| FaxNumber: | 8434976601 | ||||||||
| Practice Location | |||||||||
| Address1: | CAROLINA HEALTH SPECIALISTS 4615 OLEANDER DR | ||||||||
| Address2: | SUITE 201-A | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295771622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434499559 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 47312 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | AM9802302 | 01 | WI | DEA | OTHER | 34587800 | 05 | WI | MEDICAID |