=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588292015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIYANTA HIMANSHU PATEL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 07/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 HIGHWAY 9 E
-----------------------------------------------------
City | LITTLE RIVER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29566-7833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-390-8304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 473 CARNABY LOOP
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-3361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-390-8304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 11710
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 90133
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------