Provider Demographics
NPI:1538110663
Name:SHORT, JEFFREY KEITH
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KEITH
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 WOODLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-824-0606
Mailing Address - Fax:843-824-0909
Practice Address - Street 1:1241 WOODLAND AVENUE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-824-0606
Practice Address - Fax:843-824-0909
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC215492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC215494Medicaid
300128417OtherMEDICARE RR
SC215494Medicaid
E77820Medicare UPIN