Provider Demographics
NPI:1760445837
Name:SOUSA, JO ANN (MD)
Entity Type:Individual
Prefix:
First Name:JO ANN
Middle Name:
Last Name:SOUSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6300
Mailing Address - Country:US
Mailing Address - Phone:864-454-0888
Mailing Address - Fax:864-454-1130
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:ER ADMINISTRATION
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-6372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16074207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC160747Medicaid
SC160747Medicaid