Provider Demographics
NPI:1225018849
Name:HORSTEMEYER, DEREK L (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:L
Last Name:HORSTEMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932802
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21350207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT55124Medicaid
E74496Medicare UPIN
SCE744967726Medicare PIN