Healthcare Provider Details

I. General information

NPI: 1336376854
Provider Name (Legal Business Name): MERCY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8216 DEVON CT
MYRTLE BEACH SC
29572-4178
US

IV. Provider business mailing address

8216 DEVON CT
MYRTLE BEACH SC
29572-4178
US

V. Phone/Fax

Practice location:
  • Phone: 843-848-6480
  • Fax: 843-848-6655
Mailing address:
  • Phone: 843-848-6480
  • Fax: 843-848-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberHPC-0053
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberHPC-0053
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberHPC-0053
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberHPC-0053
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier000000191785
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerBLUECROSS BLUESHIELD OF SC CREDENTIALING FOR PALLIATIVE CARE VISITS
# 2
IdentifierGP5545
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 3
Identifier8244
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerOLD, DEACTIVATED MEDICARE B PTAN (PRIOR TO 2009)
# 4
IdentifierDQ8026
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICARE RAILROAD

VIII. Authorized Official

Name: SARA JO FAUCHER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 843-848-6480