NPIMap

Organization Active NPI

Waccamaw Dermatology, LLC

  • Dermatology Physician
  • Myrtle Beach, SC
National Provider Identifier
1962449181
Registry record updated Mar 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
WACCAMAW DERMATOLOGY, LLC
Practice address
917 Medical Circle
Myrtle Beach, SC 29572
Phone
(843) 449-0453
Fax
(843) 282-1910
NPI assigned
May 31, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 22, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brandon J. Coakley, MDNPI 1992065858
Title
Managing Partner
Phone
(843) 449-0453

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

917 Medical Circle
Myrtle Beach, SC 29572

Mailing address

917 Medical Circle
Myrtle Beach, SC 29572
Phone (843) 449-0453

Other identifiers 1

IdentifierTypeStateIssuer
GP1554MedicaidSC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC, NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080303000763 SC Part B Supplier - Clinic/Group Practice 7315021169 Receives reassigned benefits from 30 practitioners
Practice locations: Mount Pleasant, SC; Summerville, SC; Pawleys Island, SC; Myrtle Beach, SC; Dillon, SC; Conway, SC
O20250411003195 NC Part B Supplier - Clinic/Group Practice 7315021169 Receives reassigned benefits from 4 practitioners
Practice locations: Wilmington, NC

National Provider Directory

National Provider Directory

Locations

2725 Iron Gate Dr
Ste 100
Wilmington, NC 28412

834 Farrar Dr
Conway, SC 29526
Phone (843) 347-9487

505 Belle Hall Pkwy
Unit 202
Mt Pleasant, SC 29464

4573 Oleander Dr
Ste 5755
Myrtle Beach, SC 29577

917 Medical Cir
Myrtle Beach, SC 29572

8170 Rourk St
Ste 175
Myrtle Beach, SC 29572

5046 Highway 17 Byp S
Myrtle Beach, SC 29588
Phone (843) 293-2700

14880 Ocean Hwy
Pawleys Island, SC 29585
Phone (843) 237-1569

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 47

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647907200000",
    "number": "1962449181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "917 MEDICAL CIRCLE",
            "city": "MYRTLE BEACH",
            "state": "SC",
            "postal_code": "29572",
            "telephone_number": "843-449-0453",
            "fax_number": "843-282-1910"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "917 MEDICAL CIRCLE",
            "city": "MYRTLE BEACH",
            "state": "SC",
            "postal_code": "29572",
            "telephone_number": "843-449-0453",
            "fax_number": "843-282-1910"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WACCAMAW DERMATOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-31",
        "last_updated": "2022-03-22",
        "certification_date": "2022-03-22",
        "status": "A",
        "authorized_official_last_name": "COAKLEY",
        "authorized_official_first_name": "BRANDON",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "843-449-0453",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP1554",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Myrtle Beach, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.