Provider Demographics
NPI:1578552410
Name:BANKS, JERRY BURTON (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:BURTON
Last Name:BANKS
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 1:920 DOUG WHITE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4181
Mailing Address - Country:US
Mailing Address - Phone:843-848-1440
Mailing Address - Fax:843-839-2382
Practice Address - Street 1:920 DOUG WHITE DR STE 250
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4181
Practice Address - Country:US
Practice Address - Phone:843-848-1440
Practice Address - Fax:843-839-2382
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232005207Q00000X
TNMD34440207Q00000X
SC37612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505595Medicaid
SC037612200Medicaid
VA1578552410Medicaid
SC037612200Medicaid
SCSC59759167Medicare PIN
TN103I083043Medicare PIN
VAVVC774AMedicare PIN