Basic Information
| Provider Information | |||||||||
| NPI: | 1942575451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL SPECIALISTS OF WACCAMAW, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WACCAMAW SURGERY, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4367 RIVERWOOD DRIVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528390 | ||||||||
| FaxNumber: | 8436528399 | ||||||||
| Practice Location | |||||||||
| Address1: | 4367 RIVERWOOD DRIVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528390 | ||||||||
| FaxNumber: | 8436528399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2012 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | METZ | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8436528390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 26036 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GP5888 | 05 | SC | MEDICAID |