1942262621 NPI number — DR. JEREMY PATRICK ANDERSON O.D.

Table of content: DR. JEREMY PATRICK ANDERSON O.D. (NPI 1942262621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942262621 NPI number — DR. JEREMY PATRICK ANDERSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JEREMY
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1942262621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 MUSGROVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29325-2350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-833-5555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 E BLACKSTOCK RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29301-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-585-7807
Provider Business Practice Location Address Fax Number:
864-585-8272
Provider Enumeration Date:
04/06/2006

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: 152W00000X , with the licence number:  1321 , 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: AA05988525 . This is a "PROVIDER ID NUMBER" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: D13215 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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