Provider Demographics
NPI:1639123441
Name:HEVENER, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:HEVENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5470 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:COWPENS
Practice Address - State:SC
Practice Address - Zip Code:29330
Practice Address - Country:US
Practice Address - Phone:864-463-3286
Practice Address - Fax:864-463-9258
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC078427Medicaid
SC078427Medicaid
B92343Medicare ID - Type Unspecified