Provider Demographics
NPI:1598742041
Name:ADVANTAGE HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:ADVANTAGE HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-215-5000
Mailing Address - Street 1:4301 HIGHWAY 544
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6807
Mailing Address - Country:US
Mailing Address - Phone:843-215-5000
Mailing Address - Fax:843-215-5005
Practice Address - Street 1:4301 HIGHWAY 544
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6807
Practice Address - Country:US
Practice Address - Phone:843-215-5000
Practice Address - Fax:843-215-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0364207Q00000X
SC0584207Q00000X
SC0708207Q00000X
SCDO1072207Q00000X
SC0847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00057006OtherR/R MEDICARE PROVIDER ID
CI2223OtherR/R MEDICARE GROUP ID
SCGP1373Medicaid
SCP74639OtherCAROLINA CARE PLAN
SCP00134805OtherR/R MEDICARE PROVIDER ID
SCP00134805OtherR/R MEDICARE PROVIDER ID
SCP74639OtherCAROLINA CARE PLAN
SCI08559Medicare UPIN
SCAA22096003Medicare PIN
SCP74639OtherCAROLINA CARE PLAN
SCP00134805OtherR/R MEDICARE PROVIDER ID
SC=========OtherTRICARE
CI2223OtherR/R MEDICARE GROUP ID
SCE25771Medicare UPIN