Provider Demographics
NPI: | 1437158284 |
---|---|
Name: | STANCUT, PAVEL M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | PAVEL |
Middle Name: | M |
Last Name: | STANCUT |
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 3439 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORTH MYRTLE BEACH |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29582-0439 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-839-4447 |
Mailing Address - Fax: | 843-399-0123 |
Practice Address - Street 1: | 906 MEDICAL CIR |
Practice Address - Street 2: | |
Practice Address - City: | MYRTLE BEACH |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29572-4114 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-497-5929 |
Practice Address - Fax: | 843-839-1037 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-14 |
Last Update Date: | 2015-07-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 22893 | 207RN0300X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | 228934 | Medicaid | |
SC | G697525373 | Medicare PIN | |
SC | G397526072 | Medicare PIN | |
SC | G397524639 | Medicare PIN |