Provider Demographics
NPI:1811402910
Name:MCINNIS, MICHAEL (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:NP
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 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PIEDMONT ORTHOPAEDIC ASSOCIATES
Practice Address - Street 2:35 INTERNATIONAL DRIVE
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4816
Practice Address - Country:US
Practice Address - Phone:864-234-7654
Practice Address - Fax:864-675-1657
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21486363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4940Medicaid