Provider Demographics
NPI:1093719320
Name:EBERLY, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:EBERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4501 OLD SPARTANBURG RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4105
Mailing Address - Country:US
Mailing Address - Phone:864-268-1119
Mailing Address - Fax:864-268-1714
Practice Address - Street 1:4501 OLD SPARTANBURG RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4105
Practice Address - Country:US
Practice Address - Phone:864-268-1119
Practice Address - Fax:864-268-1714
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC14967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0103038OtherCAROLINA CARE PLAN
SC1035477OtherUNITED HEALTH CARE
SC149672Medicaid
SC57-0947101OtherTAX ID
SC49218OtherMEDCOST
SC149672Medicaid
SC0103038OtherCAROLINA CARE PLAN
SCE629300281Medicare ID - Type Unspecified
SC080038021Medicare ID - Type UnspecifiedMEDICARE RAILROAD