MEDICARE: MYRTLE BEACH ENDOCRINOLOGY

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	MD11983	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083872030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYRTLE BEACH ENDOCRINOLOGY

Provider Business Mailing Address
First Line	:	PO BOX 100523
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29501
Country	:	US
Telephone Number	:	843-669-5162
Fax Number	:	843-771-4482

Provider Business Practice Location Address
First Line	:	1039 44TH AVENUE NORTH
Second Line	:	SUITE 204
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577
Country	:	US
Telephone Number	:	843-839-3950
Fax Number	:	843-839-3955

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	PAUL DAVID BUNN
Credential	:	MD
Telephone Number	:	843-267-1535

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	07/16/2008

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