Healthcare Provider Details

I. General information

NPI: 1023304847
Provider Name (Legal Business Name): MARLENA MATTINGLY MASAVAGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BEAUFORT MEMORIAL OBSTETRICS & GYNECOLOGY SPECIALISTS 989 RIBAUT RD., STE 210
BEAUFORT SC
29902-5472
US

IV. Provider business mailing address

955 RIBAUT RD BMAC CREDENTIALING COORDINATOR
BEAUFORT SC
29902-5441
US

V. Phone/Fax

Practice location:
  • Phone: 843-522-7820
  • Fax: 843-522-7821
Mailing address:
  • Phone: 843-522-5674
  • Fax: 843-522-5678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number38179
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11015972A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: