Provider Demographics
NPI:1689825895
Name:PIKE, JEFFREY RUSSELL (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RUSSELL
Last Name:PIKE
Suffix:
Gender:M
Credentials:PA
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:5070 INTERNATIONAL BLVD STE 131
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6007
Practice Address - Country:US
Practice Address - Phone:843-402-5053
Practice Address - Fax:843-724-1325
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1385363AM0700X
SC1385TL363AM0700X
NC0010-002235363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA86079223OtherMEDICARE PIN
SC0744PAMedicaid