Healthcare Provider Details

I. General information

NPI: 1033131990
Provider Name (Legal Business Name): AMBULATORY CARE ANESTHESIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

PO BOX 2013
COLUMBIA SC
29202-2013
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-1062
  • Fax:
Mailing address:
  • Phone: 843-692-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierGP4352
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: DR. JOSEPH MAGGIONCALDA
Title or Position: PRESIDENT
Credential: MD
Phone: 843-692-1026