Basic Information
Provider Information | |||||||||
NPI: | 1689106403 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESMARAIS | ||||||||
FirstName: | SAVANNAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CZAPIEWSKI | ||||||||
OtherFirstName: | SAVANAH | ||||||||
OtherMiddleName: | RAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 809 82ND PKWY | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295724607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432361950 | ||||||||
FaxNumber: | 8432361952 | ||||||||
Practice Location | |||||||||
Address1: | 809 82ND PKWY | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295724607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432361950 | ||||||||
FaxNumber: | 8432361952 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2017 | ||||||||
LastUpdateDate: | 06/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | DO41046 | SC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.