Provider Demographics
NPI:1902906712
Name:BYRD, JEREMY MICHAEL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:BYRD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 N NELSON DRIVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644
Practice Address - Country:US
Practice Address - Phone:864-522-6270
Practice Address - Fax:864-522-6275
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28058207RA0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC280582Medicaid
SCP00801532OtherRR MEDICARE
SCP00801532OtherRR MEDICARE
SCAA38757951Medicare PIN