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General NPI Number Information
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NPI Number | 1023304847
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Entity Type | Individual
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Provider Name | MARLENA MATTINGLY MASAVAGE M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/20/2011
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Last Update Date | 09/24/2018
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Provider Practice Location Address
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Address Line | BEAUFORT MEMORIAL OBSTETRICS & GYNECOLOGY SPECIALISTS 989 RIBAUT RD., STE 210
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City | BEAUFORT
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State | SC
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Zip | 29902-5472
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Country | US
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Telephone | 843-522-7820
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Fax | 843-522-7821
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Provider Business Mailing Address
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Address Line | 955 RIBAUT RD BMAC CREDENTIALING COORDINATOR
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City | BEAUFORT
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State | SC
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Zip | 29902-5441
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Country | US
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Telephone | 843-522-5674
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Fax | 843-522-5678
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 38179
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 11015972A
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License Number State | IN
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