Provider Demographics
NPI:1588867345
Name:HUNNICUTT, ADDIE STARK (MD)
Entity type:Individual
Prefix:
First Name:ADDIE
Middle Name:STARK
Last Name:HUNNICUTT
Suffix:
Gender:F
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:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:STE A350
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5110
Practice Address - Fax:864-241-9206
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC238352080P0008X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC238353Medicaid
SCAA31637951Medicare PIN
SC238353Medicaid
SCAA31637951Medicare PIN