Provider Demographics
NPI:1891923546
Name:HERLONG, JASON LANE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LANE
Last Name:HERLONG
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 1:130 PHILIPPI CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-9555
Mailing Address - Country:US
Mailing Address - Phone:864-554-1966
Mailing Address - Fax:
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-819-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22503207L00000X
SC51553207L00000X, 207LP2900X, 208VP0000X
MI4301094817207L00000X
LAMD.207659207LP2900X
GA71789208VP0000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02334560Medicaid
LA2394690Medicaid
MS02334560Medicaid