Provider Demographics
NPI:1508825035
Name:JENNINGS, WILLIAM RUSSELL JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:JENNINGS
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 1:5 MEDICAL PARK DRIVE
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE PALMETTO HEALTH RICHLAND
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-6690
Mailing Address - Fax:803-434-3946
Practice Address - Street 1:5 MEDICAL PARK DRIVE
Practice Address - Street 2:STE 350 PALMETTO HEALTH RICHLAND DEPT OF EMERGENCY MED
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6690
Practice Address - Fax:803-434-3946
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24096207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC240965Medicaid
SCI257553396Medicare ID - Type Unspecified
I25755Medicare UPIN