Basic Information
| Provider Information | |||||||||
| NPI: | 1336252931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARAVELLA | ||||||||
| FirstName: | PHILIP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4615 OLEANDER DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8438394448 | ||||||||
| Practice Location | |||||||||
| Address1: | 3361 HIGHWAY 9 E | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295667826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8438394448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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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 | 207Q00000X | 35040427C | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7554 | 01 | SC | MEDICAL LICENSE | OTHER | 080080657 | 01 | OH | MEDICARE RAILROAD | OTHER | 0485069 | 05 | OH | MEDICAID |