Active NPI
Mirakle Avery
- Physician Assistant
- Columbia, SC
National Provider Identifier
1013772391
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 6095
- Practice address
- 2611 Forest Dr Ste 200
Columbia, SC 29204-2371 - Phone
- (803) 799-3263
- NPI assigned
- Feb 16, 2024
- Last updated
- Jan 15, 2026
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 6095 | SC | Primary |
Addresses
Primary practice location
2611 Forest Dr Ste 200
Columbia, SC 29204-2371
Mailing address
2611 Forest Dr Ste 200
Columbia, SC 29204-2371
Phone (804) 799-3263
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Physician Assistant
- Education
- Medical University of South Carolina College of Medicine, 2025
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
2611 Forest Dr
Suite 200
Columbia, SC 29204-2300
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6095 | SC | MD | Physician Assistant |
Interoperability endpoints
- mirakle.avery.1@17099.direct.athenahealth.com
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Interventional Pain Medicine Physician
- Columbia, SC
- NPI 1861411738
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1708041600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1768435200000",
"number": "1013772391",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2611 FOREST DR STE 200",
"city": "COLUMBIA",
"state": "SC",
"postal_code": "292042371",
"telephone_number": "804-799-3263"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2611 FOREST DR STE 200",
"city": "COLUMBIA",
"state": "SC",
"postal_code": "292042371",
"telephone_number": "803-799-3263"
}
],
"practiceLocations": [],
"basic": {
"last_name": "AVERY",
"first_name": "MIRAKLE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-02-16",
"last_updated": "2026-01-15",
"certification_date": "2026-01-15",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "SC",
"license": "6095",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Columbia, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.