=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790905867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORINNE M ADKINS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2007
-----------------------------------------------------
Last Update Date | 08/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | GRAND STAND PEDIATRICS 8120 ROURK STREET
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-449-1438
-----------------------------------------------------
Fax | 843-206-1349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | GRAND STAND PEDIATRICS 8120 ROURK STREET
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-449-1438
-----------------------------------------------------
Fax | 843-206-1349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0110001977
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 3262
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------