Provider Demographics
NPI:1972824357
Name:BHANSALY, ISHAN (MD)
Entity Type:Individual
Prefix:
First Name:ISHAN
Middle Name:
Last Name:BHANSALY
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 5
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-19
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32920208M00000X, 207Q00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC16326067OtherMEDICARE PIN
SCSC16325019OtherMEDICARE PIN
SCSC16323365OtherMEDICARE PIN
SC329200Medicaid