Provider Demographics
NPI:1417983982
Name:ACKERMANN, JEREMY JAMES (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:ACKERMANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 HWY 52
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-0995
Mailing Address - Country:US
Mailing Address - Phone:843-761-8800
Mailing Address - Fax:843-761-8824
Practice Address - Street 1:2061 HWY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-0995
Practice Address - Country:US
Practice Address - Phone:843-761-8800
Practice Address - Fax:843-761-8824
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009760Medicaid
080172610OtherRAILROAD MCARE
080172610OtherRAILROAD MCARE
SC009760Medicaid