Healthcare Provider Details

I. General information

NPI: 1194454868
Provider Name (Legal Business Name): RYAN ANTONAWICH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 10/19/2026
Certification Date: 10/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 HOLMESTOWN RD
MYRTLE BEACH SC
29588-7837
US

IV. Provider business mailing address

4320 HOLMESTOWN RD
MYRTLE BEACH SC
29588-7837
US

V. Phone/Fax

Practice location:
  • Phone: 843-652-8440
  • Fax: 843-652-8441
Mailing address:
  • Phone: 843-652-8440
  • Fax: 843-652-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number95586
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: