Provider Demographics
NPI:1144206996
Name:BAUCUM, JIMMY RAY (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:RAY
Last Name:BAUCUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD
Practice Address - Street 2:STE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-455-6900
Practice Address - Fax:864-255-5619
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14065207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC140653Medicaid
SC140653Medicaid
SCE692453640Medicare PIN
SC5863Medicare PIN
SCE692457951Medicare PIN