Provider Demographics
NPI:1730125303
Name:ANDERSON, JEFFREY STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2564 PALMETTO HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8070
Mailing Address - Country:US
Mailing Address - Phone:843-856-0527
Mailing Address - Fax:
Practice Address - Street 1:215 S BROOKS ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3113
Practice Address - Country:US
Practice Address - Phone:800-926-3772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16888207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC168883Medicaid
SC168883Medicaid