Provider Demographics
NPI:1619157294
Name:GRAND STRAND PLASTIC & RECONSTRUCTIVE SURGERY CENTER PA
Entity type:Organization
Organization Name:GRAND STRAND PLASTIC & RECONSTRUCTIVE SURGERY CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-497-2227
Mailing Address - Street 1:4610 OLEANDER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5752
Mailing Address - Country:US
Mailing Address - Phone:843-497-2227
Mailing Address - Fax:843-449-9265
Practice Address - Street 1:4610 OLEANDER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5752
Practice Address - Country:US
Practice Address - Phone:843-497-2227
Practice Address - Fax:843-449-9265
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND STRAND PLASTIC AND RECONSTRUCTIVE SURGERY CENTER, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-12
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153461Medicaid
SC153461Medicaid
SCE932103032Medicare PIN