Provider Demographics
NPI:1801865365
Name:JERVEY, CHARLES STEWART (M D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STEWART
Last Name:JERVEY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6307
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B350
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6337
Practice Address - Country:US
Practice Address - Phone:864-454-4500
Practice Address - Fax:864-454-4505
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200015262084N0400X
SC150142084N0400X
VA01012689332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200080119Medicaid
SC150142Medicaid
SCE47939Medicare UPIN