Provider Demographics
NPI:1801900030
Name:MORELAND, BENJAMIN W (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:W
Last Name:MORELAND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2673 SCARECROW WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3271
Mailing Address - Country:US
Mailing Address - Phone:843-353-7043
Mailing Address - Fax:
Practice Address - Street 1:899 ISLAND PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492
Practice Address - Country:US
Practice Address - Phone:843-856-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA-824363A00000X
SC2720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3018PAMedicaid
Q10956Medicare UPIN
KY0694530Medicare ID - Type UnspecifiedMCARE #