MEDICARE: NIRVANA PLASTIC SURGERY, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	31460	SC

General Provider Information

NPI Number	:	1023245966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIRVANA PLASTIC SURGERY, P.A.

Provider Business Mailing Address
First Line	:	8208A DEVON CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4178
Country	:	US
Telephone Number	:	843-839-2004
Fax Number	:	843-839-2011

Provider Business Practice Location Address
First Line	:	8208A DEVON CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4178
Country	:	US
Telephone Number	:	843-839-2004
Fax Number	:	843-839-2011

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHEN DAVID DUFFY
Credential	:	M.D.
Telephone Number	:	843-839-2004

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	01/18/2017

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