Healthcare Provider Details

I. General information

NPI: 1013455302
Provider Name (Legal Business Name): ALEXANDER PETKOVSEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 01/27/2022
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DOUG WHITE DR STE 210
MYRTLE BEACH SC
29572-4181
US

IV. Provider business mailing address

920 DOUG WHITE DR STE 210
MYRTLE BEACH SC
29572-4181
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-6348
  • Fax: 843-497-6351
Mailing address:
  • Phone: 843-497-6348
  • Fax: 843-497-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20710
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: