Provider Demographics
NPI:1417940792
Name:GREGORY, JONATHAN M (MD, FACC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 GLEASONS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29920-3814
Mailing Address - Country:US
Mailing Address - Phone:843-838-4208
Mailing Address - Fax:843-838-3779
Practice Address - Street 1:1414 GLEASONS LANDING DR
Practice Address - Street 2:
Practice Address - City:SAINT HELENA ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29920-3814
Practice Address - Country:US
Practice Address - Phone:843-838-4208
Practice Address - Fax:843-838-3779
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21611207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0624Medicaid
SCB437974251Medicare ID - Type Unspecified
SCGP0624Medicaid