Provider Demographics
NPI:1356412340
Name:FAJARDO, EMMANUEL ANDES (MD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ANDES
Last Name:FAJARDO
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 N A ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2142
Practice Address - Country:US
Practice Address - Phone:864-859-4480
Practice Address - Fax:864-859-3750
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32136208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC321360Medicaid
SCAA4134OtherMEDICARE
SCAPPROVEDMedicaid
MS00119124Medicaid
SCP00801536OtherRR MEDICARE
MS110001662Medicare PIN
SCAA41343640Medicare PIN