Provider Demographics
NPI:1659302537
Name:NIENHUIS, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:NIENHUIS
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 7003
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29021-7003
Mailing Address - Country:US
Mailing Address - Phone:803-424-5165
Mailing Address - Fax:803-408-0356
Practice Address - Street 1:40 PINNACLE PKWY
Practice Address - Street 2:SUITE 208
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8390
Practice Address - Country:US
Practice Address - Phone:803-424-5165
Practice Address - Fax:803-408-0356
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901247Medicaid
NC2006363Medicare ID - Type Unspecified
NC5901247Medicaid