Provider Demographics
NPI:1629274964
Name:JUAN, EMERSON (DO)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:
Last Name:JUAN
Suffix:
Gender:M
Credentials:DO
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:EMERGENCY CENTER
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7025
Practice Address - Fax:864-560-7388
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00705207P00000X
SCTL1106207P00000X
SC1106207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC011061Medicaid
SC201626OtherMEDCOST
NC5907926Medicaid
SC20066217OtherSELECT HEALTH
SCAA21749068OtherMEDICARE PIN
SCAA21748510OtherMEDICARE PIN
SCP00751117Medicare PIN
SCAA21748510Medicare PIN
SCAA21749068Medicare PIN