MEDICARE: SEACOAST ENT & FACIAL PLASTIC SURGERY, PA

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	207YS0123X	Facial Plastic Surgery Physician	28577	SC

General Provider Information

NPI Number	:	1386698165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEACOAST ENT & FACIAL PLASTIC SURGERY, PA

Provider Business Mailing Address
First Line	:	4000 HIGHWAY 9 E
Second Line	:	SUITE 270
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-7833
Country	:	US
Telephone Number	:	843-390-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 HIGHWAY 9 E
Second Line	:	SUITE 270
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-7833
Country	:	US
Telephone Number	:	843-390-4200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL DAVID PETERS
Credential	:	M.D.
Telephone Number	:	843-390-4200

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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