Provider Demographics
NPI:1477181741
Name:COLLINS, DOMINIC CHRISTIAN
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:CHRISTIAN
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GRAND STRAND MEDICAL CENTER - GME OFFICE
Mailing Address - Street 2:809 82ND PARKWAY
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:843-236-1950
Mailing Address - Fax:843-236-1952
Practice Address - Street 1:GRAND STRAND MEDICAL CENTER - GME OFFICE
Practice Address - Street 2:809 82ND PARKWAY
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-236-1950
Practice Address - Fax:843-236-1952
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCLL83177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program