Provider Demographics
NPI:1063892008
Name:JAENICKE, MATTHEW WALTER (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WALTER
Last Name:JAENICKE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 JOHNNIE DODDS BLVD SUITE 2A
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-881-9971
Mailing Address - Fax:843-881-9973
Practice Address - Street 1:890 JOHNNIE DODDS BLVD SUITE 2A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-881-9971
Practice Address - Fax:843-881-9973
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT390200000X
SC38299207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0000030538Medicaid