Provider Demographics
NPI:1538139803
Name:JERVEY EYE GROUP, PA
Entity Type:Organization
Organization Name:JERVEY EYE GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-250-6487
Mailing Address - Street 1:601 HALTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3403
Mailing Address - Country:US
Mailing Address - Phone:864-250-6487
Mailing Address - Fax:864-250-6475
Practice Address - Street 1:5 STEVENS ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4528
Practice Address - Country:US
Practice Address - Phone:864-250-6487
Practice Address - Fax:864-250-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207W00000X, 152W00000X
SC23038207W00000X, 207W00000X
SC15210207L00000X
SC14145207L00000X
SC12149207L00000X
SC5639207L00000X
SC16413207L00000X
SC16323207L00000X
SC26612207L00000X
SC20313207W00000X
SC8984207W00000X
SC13871207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9938OtherMEDICAID DMERC
SCDM0382OtherMEDICAID DMERC NUMBER
SCCN1548OtherMEDICARE RAILROAD
SCGP0900Medicaid
SCDA9938OtherMEDICAID DMERC
SC0813910003Medicare NSC