Provider Demographics
NPI:1629002282
Name:BAHAN, MARC G (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:G
Last Name:BAHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-1150
Mailing Address - Country:US
Mailing Address - Phone:843-431-2650
Mailing Address - Fax:843-431-2647
Practice Address - Street 1:2845 E HIGHWAY 76
Practice Address - Street 2:SUITE 5
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6037
Practice Address - Country:US
Practice Address - Phone:843-431-2650
Practice Address - Fax:843-431-2647
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC121Medicaid
SCRHC203OtherRHC
SCGP9493OtherMEDICARE
SCGP5462Medicaid
SCGP9493OtherMEDICARE