Provider Demographics
NPI:1184758120
Name:REGAN, MICHAEL GERARD (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GERARD
Last Name:REGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CENTRAL AVE STE 300B
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3086
Mailing Address - Country:US
Mailing Address - Phone:843-569-1212
Mailing Address - Fax:843-569-1909
Practice Address - Street 1:105 CENTRAL AVE STE 300B
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445
Practice Address - Country:US
Practice Address - Phone:843-569-1212
Practice Address - Fax:843-569-1909
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1171111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1171Medicaid
SC571071009OtherBLUE CROSS BLUE SHIELD