Provider Demographics
NPI:1023304847
Name:MASAVAGE, MARLENA MATTINGLY (MD)
Entity type:Individual
Prefix:DR
First Name:MARLENA
Middle Name:MATTINGLY
Last Name:MASAVAGE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:BMAC CREDENTIALING COORDINATOR
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-5674
Mailing Address - Fax:843-522-5678
Practice Address - Street 1:BEAUFORT MEMORIAL OBSTETRICS & GYNECOLOGY SPECIALISTS
Practice Address - Street 2:989 RIBAUT RD., STE 210
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5472
Practice Address - Country:US
Practice Address - Phone:843-522-7820
Practice Address - Fax:843-522-7821
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2018-09-24
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Provider Licenses
StateLicense IDTaxonomies
SC38179207V00000X
IN11015972A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC38179OtherSTATE MEDICAL LICENSE BOARD