Provider Demographics
NPI:1437308814
Name:WACCAMAW DERMATOLOGY AND PLASTIC SURGERY
Entity Type:Organization
Organization Name:WACCAMAW DERMATOLOGY AND PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:QUIRKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-449-0453
Mailing Address - Street 1:917 MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4116
Mailing Address - Country:US
Mailing Address - Phone:843-449-0453
Mailing Address - Fax:843-497-4822
Practice Address - Street 1:917 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4116
Practice Address - Country:US
Practice Address - Phone:843-449-0453
Practice Address - Fax:843-497-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1554Medicaid
SC5327Medicare PIN
SC5216Medicare PIN
SC5401Medicare PIN