Healthcare Provider Details

I. General information

NPI: 1942266788
Provider Name (Legal Business Name): THOMAS WILLIAM PETRUSICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 ROURK ST
MYRTLE BEACH SC
29572-4127
US

IV. Provider business mailing address

8120 ROURK ST
MYRTLE BEACH SC
29572-4127
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-1438
  • Fax: 843-286-1349
Mailing address:
  • Phone: 843-449-1438
  • Fax: 843-286-1349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7085
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: