Healthcare Provider Details

I. General information

NPI: 1962514190
Provider Name (Legal Business Name): GAVIN MICHAEL VAUGHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 HIGHWAY 17
MURRELLS INLET SC
29576-5098
US

IV. Provider business mailing address

PO BOX 1209
MURRELLS INLET SC
29576-1209
US

V. Phone/Fax

Practice location:
  • Phone: 843-652-8160
  • Fax: 843-652-8161
Mailing address:
  • Phone: 843-652-8220
  • Fax: 843-527-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number37356
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number37356
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierTL37356
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: