Organization
PORT CITY PLASTIC SURGERY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIAN G WIDENHOUSE M.D. (OWNER)
(843) 856-8398
Entity
Organization
Contact information
Practice address
2683 LAKE PARK DR, NORTH CHARLESTON, SC 29406-9100
(843) 518-5000
Mailing address
43 WOODFORD ST, DANIEL ISLAND, SC 29492-7964
(843) 856-8398
Taxonomy
Speciality
Code
Description
License number
State
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
200096
SC
Other
Enumeration date
06/01/2009
Last updated
03/09/2017
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