Provider Demographics
NPI: | 1366448771 |
---|---|
Name: | FLEMING, JOHN RUSSELL JR (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JOHN |
Middle Name: | RUSSELL |
Last Name: | FLEMING |
Suffix: | JR |
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: | 1035 FOXRIDGE CT |
Mailing Address - Street 2: | |
Mailing Address - City: | SUMTER |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29150-1732 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 803-236-9180 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1229 ALICE DR |
Practice Address - Street 2: | |
Practice Address - City: | SUMTER |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29150-1970 |
Practice Address - Country: | US |
Practice Address - Phone: | 803-905-2273 |
Practice Address - Fax: | 803-905-7775 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-22 |
Last Update Date: | 2019-12-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 20821 | 207QH0002X, 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 207QH0002X | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | T49196 | Medicaid | |
SC | G306139326 | Medicare PIN | |
SC | T49196 | Medicaid | |
SC | G306137436 | Medicare PIN |