Provider Demographics
NPI:1588604433
Name:DOCHERTY, JON H SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:H
Last Name:DOCHERTY
Suffix:SR
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 1:1594 FREEDOM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6046
Mailing Address - Country:US
Mailing Address - Phone:843-674-4760
Mailing Address - Fax:
Practice Address - Street 1:1594 FREEDOM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6046
Practice Address - Country:US
Practice Address - Phone:843-674-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4306Medicaid
SC077552Medicaid
SCCG3543OtherMEDICARE RAILROAD GROUP
SCP00844614OtherMEDICARE RAILROAD INDIVIDUAL
SCP00844614OtherMEDICARE RAILROAD INDIVIDUAL
SCGP4306Medicaid