Provider Demographics
NPI:1790947596
Name:BOYLAN, MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOYLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6941 N TRENHOLM RD STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1715
Mailing Address - Country:US
Mailing Address - Phone:803-667-4190
Mailing Address - Fax:803-902-8077
Practice Address - Street 1:6941 N TRENHOLM RD STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-1715
Practice Address - Country:US
Practice Address - Phone:803-667-4190
Practice Address - Fax:803-902-8077
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL31065207Q00000X
SC31065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC310657Medicaid
SCAA71187654Medicare PIN
SCAA7118F935Medicare PIN
SCAA71182353Medicare PIN