Provider Demographics
NPI:1124370713
Name:JACQUETTE CALDWELL MD PA
Entity Type:Organization
Organization Name:JACQUETTE CALDWELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-699-9226
Mailing Address - Street 1:28 WILDEOAK CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-3292
Mailing Address - Country:US
Mailing Address - Phone:803-699-9226
Mailing Address - Fax:
Practice Address - Street 1:28 WILDEOAK CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-3292
Practice Address - Country:US
Practice Address - Phone:803-699-9226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC023105261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCH33467Medicare UPIN