Provider Demographics
NPI:1659474658
Name:VANDERGRIFF, JOSEPH VANCE (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:VANCE
Last Name:VANDERGRIFF
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 51913
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0032
Mailing Address - Country:US
Mailing Address - Phone:843-945-3030
Mailing Address - Fax:
Practice Address - Street 1:185 FRESH DR STE A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4436
Practice Address - Country:US
Practice Address - Phone:843-945-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3722Medicaid
423858Medicare Oscar/Certification
SC5078Medicare PIN
423859Medicare Oscar/Certification
SCGP3722Medicaid