Basic Information
| Provider Information | |||||||||
| NPI: | 1205065539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POURNARAS | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | BETTINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POLYDOROPOULOS | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | BETTINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4615 OLEANDER DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8438394448 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8438394448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2009 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TL35193 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | TL35193 | 01 | SC | STATE LICENSE | OTHER | 351933 | 05 | SC | MEDICAID |