Provider Demographics
NPI:1124099890
Name:TAYLOR, JETER P (MD)
Entity type:Individual
Prefix:
First Name:JETER
Middle Name:P
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:P
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 350
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6896
Practice Address - Country:US
Practice Address - Phone:803-434-1663
Practice Address - Fax:803-434-3894
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13957207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC139576Medicaid
E67452Medicare UPIN
SCE674525742Medicare PIN
SC139576Medicaid