Provider Demographics
NPI:1043593395
Name:WACCAMAW ULTRASOUND & DIAGNOSTICS
Entity Type:Organization
Organization Name:WACCAMAW ULTRASOUND & DIAGNOSTICS
Other - Org Name:MEDICAL CENTER DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-642-9085
Mailing Address - Street 1:1515 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7507
Mailing Address - Country:US
Mailing Address - Phone:910-642-9085
Mailing Address - Fax:
Practice Address - Street 1:112 E WHITE OAK ST
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450-2128
Practice Address - Country:US
Practice Address - Phone:910-642-9085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890129LMedicaid
NC890129LMedicaid