Provider Demographics
NPI:1730201112
Name:BOULLION, CHRISTOPHER GARRETT (DO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:GARRETT
Last Name:BOULLION
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DOUG WHITE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4180
Mailing Address - Country:US
Mailing Address - Phone:843-848-1440
Mailing Address - Fax:843-839-1654
Practice Address - Street 1:920 DOUG WHITE DR STE 130
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4180
Practice Address - Country:US
Practice Address - Phone:843-848-1440
Practice Address - Fax:843-839-1654
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016197207X00000X
SC1429207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC01429100Medicaid
SCAA55189657Medicare PIN