Provider Demographics
NPI:1487722559
Name:MYERS PODIATRY CLINIC
Entity type:Organization
Organization Name:MYERS PODIATRY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-431-2780
Mailing Address - Street 1:2845 E HIGHWAY 76
Mailing Address - Street 2:MEDICAL PARK 2, STE 1
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6037
Mailing Address - Country:US
Mailing Address - Phone:843-431-2780
Mailing Address - Fax:
Practice Address - Street 1:2845 E HIGHWAY 76
Practice Address - Street 2:MEDICAL PARK 2, STE 1
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6037
Practice Address - Country:US
Practice Address - Phone:843-431-2780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYERS PODIATRY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-30
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 531332B00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9923Medicaid
SCGP9923Medicaid
5425660002Medicare NSC