Provider Demographics
NPI:1558575217
Name:EXECUTIVE COURT MEDICAL SPECIALIST P.C.
Entity Type:Organization
Organization Name:EXECUTIVE COURT MEDICAL SPECIALIST P.C.
Other - Org Name:AKA E C MEDICAL SPECIALIST
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-839-4505
Mailing Address - Street 1:4701 OLEANDER DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577
Mailing Address - Country:US
Mailing Address - Phone:843-497-6301
Mailing Address - Fax:843-497-6506
Practice Address - Street 1:997 HWY 17 BUSINESS SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6084
Practice Address - Country:US
Practice Address - Phone:843-839-4505
Practice Address - Fax:843-839-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15450207RG0300X
SC15451207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0772Medicaid
SC1558345686OtherNPI
SCGP0772Medicaid
SC1558345686OtherNPI
SCE861915200Medicare ID - Type Unspecified