Provider Demographics
NPI:1760431035
Name:JERVEY, EDWARD D (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:D
Last Name:JERVEY
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 1:113 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5608
Mailing Address - Country:US
Mailing Address - Phone:864-269-3333
Mailing Address - Fax:864-295-1288
Practice Address - Street 1:113 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-269-3333
Practice Address - Fax:864-295-1288
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5266207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB916671571OtherMEDICARE UPIN GROUP NUMBER GREENVILLE OFFICE
SCB916676180OtherMEDICARE UPIN GROUP NUMBER GREER OFFICE
1760431035OtherNPI
SC52668Medicaid
SC52668Medicaid