Basic Information
| Provider Information | |||||||||
| NPI: | 1780020446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN MYRTLE INPATIENT SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37765 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191015065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 82ND PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 09/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | BYRNE | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8005078874 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.