1164943213 NPI number — JACOB LUKE WAYLAND MD

Table of content: JACOB LUKE WAYLAND MD (NPI 1164943213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164943213 NPI number — JACOB LUKE WAYLAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAYLAND
Provider First Name:
JACOB
Provider Middle Name:
LUKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1164943213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29171-6069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LEXINGTON MEDICAL CENTER-EMERGENCY MEDICINE DEPT
Provider Second Line Business Practice Location Address:
2720 SUNSET BLVD
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-791-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2017

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: 207P00000X , with the licence number:  LL51190 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 51190 , 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)