Provider Demographics
NPI:1982288999
Name:NILES, ADDISON RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:RANDOLPH
Last Name:NILES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADDISON
Other - Middle Name:MARIE
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:701 GROVE ROAD
Mailing Address - Street 2:5TH FLOOR SUPPORT TOWER
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE ROAD
Practice Address - Street 2:5TH FLOOR SUPPORT TOWER
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL85939207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program