1063519064 NPI number — TERESA MARY KILGORE DO

Table of content: (NPI 1699290643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063519064 NPI number — TERESA MARY KILGORE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILGORE
Provider First Name:
TERESA
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOLLEY
Provider Other First Name:
TERESA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063519064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 ENTERPRISE BLVD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-6300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-454-0888
Provider Business Mailing Address Fax Number:
864-454-1130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 LAUREL ST STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29204-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-227-5320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

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: 207R00000X , with the licence number:  279 , 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: 576007863 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 002794 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-6007863 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 57-6007863 . This is a "BLUE CHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 110234017 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 57-6007863 . This is a "TRICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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