Healthcare Provider Details

I. General information

NPI: 1891616884
Provider Name (Legal Business Name): KEVAN FEGELY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3874 RENEE DR UNIT D
MYRTLE BEACH SC
29579-4358
US

IV. Provider business mailing address

3874 RENEE DR UNIT D
MYRTLE BEACH SC
29579-4358
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-4500
  • Fax: 843-903-4505
Mailing address:
  • Phone: 843-903-4500
  • Fax: 843-903-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number245720
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: