Provider Demographics
NPI:1407953136
Name:JANSE, MELISSA CLARK (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CLARK
Last Name:JANSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:ER ADMINISTRATION
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-6372
Practice Address - Fax:864-455-1130
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21164207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20028605OtherSELECT HEALTH
SC57-6007863OtherTRICARE
SC211648Medicaid
SC211648Medicaid
SC211648Medicaid