Provider Demographics
NPI:1700856077
Name:JERVEY EYE GROUP, PA
Entity Type:Organization
Organization Name:JERVEY EYE GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-458-7956
Mailing Address - Street 1:601 HALTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3403
Mailing Address - Country:US
Mailing Address - Phone:864-458-7956
Mailing Address - Fax:864-458-8390
Practice Address - Street 1:220 S PENDLETON ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3048
Practice Address - Country:US
Practice Address - Phone:864-859-3233
Practice Address - Fax:864-850-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC910152W00000X
SC1362152W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0898Medicaid
SCDA9934Medicaid
SCDM0384OtherMEDICAID DMERC
SCCN1549OtherMEDICARE RAILROAD
SC4626Medicare PIN
SC0813910005Medicare NSC