1285080747 NPI number — DR. JESSICA L OBEYSEKARE M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285080747 NPI number — DR. JESSICA L OBEYSEKARE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBEYSEKARE
Provider First Name:
JESSICA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285080747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-455-6375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 PHYSICIANS DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29650-2446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-797-9170
Provider Business Practice Location Address Fax Number:
864-797-9175
Provider Enumeration Date:
05/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  LP03590 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 83940 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 839409 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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