Provider Demographics
NPI:1881670941
Name:CHAMP, JERRY D (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:CHAMP
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 1:100 HEALTHY WAY STE 1250
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-7917
Mailing Address - Country:US
Mailing Address - Phone:864-512-6927
Mailing Address - Fax:864-512-6687
Practice Address - Street 1:100 HEALTHY WAY STE 1250
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7917
Practice Address - Country:US
Practice Address - Phone:864-512-6927
Practice Address - Fax:864-512-6687
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19168207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC191688Medicaid
SCP00970760OtherRR MEDICARE
SC191688Medicaid
SCG470827951Medicare PIN
SCAA52547742Medicare PIN
SC5863Medicare PIN
SCG470823640Medicare PIN