Healthcare Provider Details

I. General information

NPI: 1467747568
Provider Name (Legal Business Name): NATHANIEL R EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 VILLAGE CENTER BLVD STE 200
MYRTLE BEACH SC
29579-6706
US

IV. Provider business mailing address

7221 HAGUE RD
INDIANAPOLIS IN
46256-1925
US

V. Phone/Fax

Practice location:
  • Phone: 843-236-3222
  • Fax: 843-236-3005
Mailing address:
  • Phone: 812-240-4763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number39886
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: