Provider Demographics
NPI:1205035342
Name:CRISP, JEREMY R (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:CRISP
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 POLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2806
Practice Address - Country:US
Practice Address - Phone:803-699-7255
Practice Address - Fax:803-699-0848
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29768207Q00000X
SCLL29768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA53772353OtherMEDICARE PTAN
SC297681Medicaid