Provider Demographics
NPI:1922051150
Name:COLE, JACK MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MARTIN
Last Name:COLE
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:
Practice Address - Street 1:133 N HOWARD AVE
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-1507
Practice Address - Country:US
Practice Address - Phone:864-457-3838
Practice Address - Fax:864-560-9532
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCJ0086633OtherMEDICARE PIN
SCSCJ0086084OtherMEDICARE PIN
SCSCJ008J577OtherMEDICARE PIN
SC159036Medicaid
SCP01397050OtherRAILROAD MEDICARE
SCSCJ0085019OtherMEDICARE PIN
SCSCJ0085121OtherMEDICARE PIN
SCSCJ0086067OtherMEDICARE PIN