Basic Information
| Provider Information | |||||||||
| NPI: | 1427518265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DONOVAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | GRAND STRAND MEDICAL CENTER 809 82ND PARKWAY | ||||||||
| Address2: | GME OFFICE | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921752 | ||||||||
| FaxNumber: | 8436921904 | ||||||||
| Practice Location | |||||||||
| Address1: | GRAND STRAND MEDICAL CENTER 809 82ND PARKWAY | ||||||||
| Address2: | GME OFFICE | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921752 | ||||||||
| FaxNumber: | 8436921904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2019 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 82339 | SC | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.