Provider Demographics
NPI:1942575451
Name:SURGICAL SPECIALISTS OF WACCAMAW, LLC
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF WACCAMAW, LLC
Other - Org Name:WACCAMAW SURGERY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:METZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-652-8390
Mailing Address - Street 1:4367 RIVERWOOD DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29440
Mailing Address - Country:US
Mailing Address - Phone:843-652-8390
Mailing Address - Fax:843-652-8399
Practice Address - Street 1:4367 RIVERWOOD DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-652-8390
Practice Address - Fax:843-652-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26036208600000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5888Medicaid