Provider Demographics
NPI:1639486160
Name:INTAPHAN, JARED M (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:M
Last Name:INTAPHAN
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 1:9150 MEDCOM ST STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-572-3330
Mailing Address - Fax:
Practice Address - Street 1:9150 MEDCOM ST STE B
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-572-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD39445207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
SCMD39455207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC394451Medicaid