Healthcare Provider Details

I. General information

NPI: 1033815550
Provider Name (Legal Business Name): BARRY LIPPMAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 PETERSON ST
MYRTLE BEACH SC
29577-1405
US

IV. Provider business mailing address

PO BOX 261954
CONWAY SC
29528-6054
US

V. Phone/Fax

Practice location:
  • Phone: 843-421-1772
  • Fax:
Mailing address:
  • Phone: 843-421-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberSC029801
License Number StateSC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: