Healthcare Provider Details

I. General information

NPI: 1194775429
Provider Name (Legal Business Name): MICHAEL D PETERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date: 06/17/2024
Reactivation Date: 07/19/2024

III. Provider practice location address

3806 SAWTELL RD
LITTLE RIVER SC
29566-7873
US

IV. Provider business mailing address

1859 HICKORY LN
LONGS SC
29568-6519
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-9090
  • Fax: 843-663-9091
Mailing address:
  • Phone: 843-222-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2013-01576
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD28577
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: