Basic Information
| Provider Information | |||||||||
| NPI: | 1700857638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVERT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BERNARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 W FARIS RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642954410 | ||||||||
| FaxNumber: | 8642691386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14929 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 14929 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00813599 | 01 | SC | RAILROAD MEDICARE | OTHER | 149299 | 05 | SC | MEDICAID |