Basic Information
| Provider Information | |||||||||
| NPI: | 1871835363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMBERTSON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7809 MONARCH DR | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724293 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008414236 | ||||||||
| FaxNumber: | 8434978566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 82112 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2017-01019 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 821123 | 05 | SC | MEDICAID |