Provider Demographics
NPI:1083872030
Name:MYRTLE BEACH ENDOCRINOLOGY
Entity Type:Organization
Organization Name:MYRTLE BEACH ENDOCRINOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BUNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-267-1535
Mailing Address - Street 1:PO BOX 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-771-4482
Practice Address - Street 1:1039 44TH AVENUE NORTH
Practice Address - Street 2:SUITE 204
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-839-3950
Practice Address - Fax:843-839-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD11983207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC119838Medicaid
NC89064V0Medicaid