Basic Information
| Provider Information | |||||||||
| NPI: | 1215061429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACH ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7276 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037651838 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 MEDICAL CIRCLE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | MAGGIONCALDA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8436921062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GP4651 | 05 | SC | MEDICAID |