Healthcare Provider Details

I. General information

NPI: 1760891881
Provider Name (Legal Business Name): JILL F PHELAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3076 DICK POND RD UNIT 4
MYRTLE BEACH SC
29588-7992
US

IV. Provider business mailing address

PO BOX 2397
PAWLEYS ISLAND SC
29585-2397
US

V. Phone/Fax

Practice location:
  • Phone: 843-831-0163
  • Fax: 843-831-0173
Mailing address:
  • Phone: 843-235-0200
  • Fax: 843-314-0013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7455
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP01386566
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerRAILROAD MEDICARE PRS II LLC
# 2
IdentifierP01386415
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerRAILROAD MEDICARE PRS 4 LLC
# 3
IdentifierP01386378
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerRAILROAD MEDICARE PROFESSIONAL REHABILITATION SERVICES INC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: