Healthcare Provider Details

I. General information

NPI: 1437158284
Provider Name (Legal Business Name): PAVEL M STANCUT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 MEDICAL CIR
MYRTLE BEACH SC
29572-4114
US

IV. Provider business mailing address

PO BOX 3439
NORTH MYRTLE BEACH SC
29582-0439
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-5929
  • Fax: 843-839-1037
Mailing address:
  • Phone: 843-839-4447
  • Fax: 843-399-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number22893
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22893
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier228934
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: