Provider Demographics
NPI: | 1518964626 |
---|---|
Name: | BJERKEN, DAVID SCOTT (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DAVID |
Middle Name: | SCOTT |
Last Name: | BJERKEN |
Suffix: | |
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: | PO BOX 3239 |
Mailing Address - Street 2: | |
Mailing Address - City: | FLORENCE |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29502-3239 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-777-7120 |
Mailing Address - Fax: | 843-777-7102 |
Practice Address - Street 1: | 3980 HIGHWAY 9 E STE 240 |
Practice Address - Street 2: | |
Practice Address - City: | LITTLE RIVER |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29566-8164 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-366-3755 |
Practice Address - Fax: | 843-366-3750 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-05 |
Last Update Date: | 2021-02-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 13600 | 2086S0129X, 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | 136007 | Medicaid | |
FL | U14444 | Medicare ID - Type Unspecified | |
FL | P00077477 | Medicare PIN | |
E83967 | Medicare UPIN |