Provider Demographics
NPI:1821181868
Name:BACK, JERRY G (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:G
Last Name:BACK
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 1:2845 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-863-8100
Mailing Address - Fax:843-553-2122
Practice Address - Street 1:2845 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9172
Practice Address - Country:US
Practice Address - Phone:843-863-8100
Practice Address - Fax:843-553-2122
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC495158OtherMEDICARE GROUP NUMBER
CO807694Medicare PIN
COC807694Medicare PIN
COC495158OtherMEDICARE GROUP NUMBER