1912965591 NPI number — JERRY L ACOSTA M.D.

Table of content: JERRY L ACOSTA M.D. (NPI 1912965591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912965591 NPI number — JERRY L ACOSTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACOSTA
Provider First Name:
JERRY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912965591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 SAINT FRANCIS DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-3965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-255-1317
Provider Business Mailing Address Fax Number:
864-255-1318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 SAINT FRANCIS DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29601-3965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
264-255-1317
Provider Business Practice Location Address Fax Number:
864-255-1318
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  7641 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP3950 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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