Provider Demographics
NPI:1891824355
Name:AVERILL, NATHAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JOHN
Last Name:AVERILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:2061 HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-5017
Practice Address - Country:US
Practice Address - Phone:843-761-8800
Practice Address - Fax:843-761-8824
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28895207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC288799Medicaid