Provider Demographics
NPI:1609079201
Name:INSTITUTE OF ELECTROPHYSIOLOGY
Entity type:Organization
Organization Name:INSTITUTE OF ELECTROPHYSIOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:JARAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-602-6262
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29597-0810
Mailing Address - Country:US
Mailing Address - Phone:843-602-2882
Mailing Address - Fax:843-964-0022
Practice Address - Street 1:4420 OLEANDER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5720
Practice Address - Country:US
Practice Address - Phone:843-602-2882
Practice Address - Fax:843-946-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG33734Medicare UPIN