Basic Information
| Provider Information | |||||||||
| NPI: | 1851383459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5046 HIGHWAY 17 BYP S | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295884503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432345139 | ||||||||
| FaxNumber: | 8432346822 | ||||||||
| Practice Location | |||||||||
| Address1: | 4630 HWY 17 BYPASS | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433571299 | ||||||||
| FaxNumber: | 8433572264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12647 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 12647 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 126474 | 05 | SC | MEDICAID | GP0975 | 05 | SC | MEDICAID |