Basic Information
| Provider Information | |||||||||
| NPI: | 1790921161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMAN'S MEDICAL CENTER P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4728 JENN DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432368888 | ||||||||
| FaxNumber: | 8432365088 | ||||||||
| Practice Location | |||||||||
| Address1: | 8004 MYRTLE TRACE DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477216 | ||||||||
| FaxNumber: | 8433477218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2009 | ||||||||
| LastUpdateDate: | 01/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | LEVENSON | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8433477216 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 09347 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | PC6427 | 05 | SC | MEDICAID |