MEDICARE: PORT CITY PLASTIC SURGERY, LLC

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	2086S0122X	Plastic and Reconstructive Surgery Physician	200096	SC

General Provider Information

NPI Number	:	1437385788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT CITY PLASTIC SURGERY, LLC

Provider Business Mailing Address
First Line	:	43 WOODFORD ST
Second Line	:
City	:	DANIEL ISLAND
State	:	SC
Zip	:	29492-7964
Country	:	US
Telephone Number	:	843-856-8398
Fax Number	:

Provider Business Practice Location Address
First Line	:	2683 LAKE PARK DR
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9100
Country	:	US
Telephone Number	:	843-518-5000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN G WIDENHOUSE
Credential	:	M.D.
Telephone Number	:	843-856-8398

Provider Enumeration Date	:	06/01/2009
Last Update Date	:	03/09/2017

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