Healthcare Provider Details

I. General information

NPI: 1386698165
Provider Name (Legal Business Name): SEACOAST ENT & FACIAL PLASTIC SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 HIGHWAY 9 E SUITE 270
LITTLE RIVER SC
29566-7833
US

IV. Provider business mailing address

4000 HIGHWAY 9 E SUITE 270
LITTLE RIVER SC
29566-7833
US

V. Phone/Fax

Practice location:
  • Phone: 843-390-4200
  • Fax:
Mailing address:
  • Phone: 843-390-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number28577
License Number StateSC

VIII. Authorized Official

Name: MR. MICHAEL DAVID PETERS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 843-390-4200