Provider Demographics
NPI:1497418925
Name:MATHIS, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6069 CASTLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-3020
Mailing Address - Country:US
Mailing Address - Phone:803-412-7839
Mailing Address - Fax:
Practice Address - Street 1:701 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-3525
Practice Address - Country:US
Practice Address - Phone:803-323-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWFQ493M98607OtherBLUE CROSS AND BLUE SHIELD