Provider Demographics
NPI:1710319645
Name:J VANCE VANDERGRIFF MD, LLC
Entity Type:Organization
Organization Name:J VANCE VANDERGRIFF MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:VANDERGRIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-461-0166
Mailing Address - Street 1:PO BOX 1749
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3955 HIGHWAY 17 BYPASS
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576
Practice Address - Country:US
Practice Address - Phone:843-461-0166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT58261Medicaid
SCT58261Medicaid