Provider Demographics
NPI:1659908507
Name:FAY, JEROME LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:LAWRENCE
Last Name:FAY
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 1:169 ASHLEY AVE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL MSC 333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-9125
Mailing Address - Country:US
Mailing Address - Phone:843-792-3551
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL MSC 333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-9125
Practice Address - Country:US
Practice Address - Phone:843-792-3551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL84247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine