Healthcare Provider Details

I. General information

NPI: 1588614192
Provider Name (Legal Business Name): GRAND STRAND PEDIATRICS & ADOLESCENT MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/25/2014
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 Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number7085
License Number StateSC

VIII. Authorized Official

Name: DR. THOMAS W PETRUSICK
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 843-449-1438