Provider Demographics
NPI:1578623039
Name:GRAND STRAND GYNECOLOGY
Entity Type:Organization
Organization Name:GRAND STRAND GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-449-5553
Mailing Address - Street 1:4728 JENN DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5714
Mailing Address - Country:US
Mailing Address - Phone:843-449-5553
Mailing Address - Fax:843-449-4453
Practice Address - Street 1:911 MEDICAL CIR
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:843-449-5553
Practice Address - Fax:843-449-4453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4575Medicaid
SCD18222Medicare UPIN
SCPA4575Medicaid
SCC68828Medicare UPIN
SC7526Medicare ID - Type UnspecifiedGROUP #
SCG38127Medicare UPIN