Provider Demographics
NPI:1164733374
Name:GEORGE, JOHN DERRICK (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DERRICK
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 VERDAE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4021
Mailing Address - Country:US
Mailing Address - Phone:864-516-1783
Mailing Address - Fax:
Practice Address - Street 1:525 VERDAE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4021
Practice Address - Country:US
Practice Address - Phone:864-516-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1408208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01379488OtherRAILROAD MEDICARE
SC014086Medicaid
SCSC10159068Medicare PIN
SC014086Medicaid
SCSC10155019Medicare PIN