Provider Demographics
NPI:1902860935
Name:KEEFE, JERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:KEEFE
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 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2647
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:
Practice Address - Street 1:3424 SHELBY RAY CT
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5838
Practice Address - Country:US
Practice Address - Phone:843-402-6834
Practice Address - Fax:843-573-9963
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153595Medicaid
SC153595Medicaid