Provider Demographics
NPI:1881657153
Name:PURCELL, JERRY S (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:PURCELL
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 1:1208 ELLA ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4839
Mailing Address - Country:US
Mailing Address - Phone:864-965-9150
Mailing Address - Fax:864-659-6549
Practice Address - Street 1:1208 ELLA ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4839
Practice Address - Country:US
Practice Address - Phone:864-965-9150
Practice Address - Fax:864-965-9654
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC218641Medicaid
NC5901065Medicaid
GA967617053AMedicaid
SCP00229539Medicare PIN
SC4542Medicare PIN
SC1153Medicare PIN
SCH61846Medicare UPIN
GA967617053AMedicaid