MEDICARE: MAGNOLIA OB-GYN LLC OF MYRTLE BEACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1366546608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA OB-GYN LLC OF MYRTLE BEACH

Provider Business Mailing Address
First Line	:	8203 NIGELS DR
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4177
Country	:	US
Telephone Number	:	843-449-5848
Fax Number	:	843-692-0841

Provider Business Practice Location Address
First Line	:	8203 NIGELS DR
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4177
Country	:	US
Telephone Number	:	843-449-5848
Fax Number	:	843-692-0841

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. CHERYL ANN GACH
Credential	:
Telephone Number	:	845-449-5848

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	11/03/2011

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