Provider Demographics
NPI:1649297615
Name:SOHN, JAE I (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:I
Last Name:SOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N FANT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5702
Mailing Address - Country:US
Mailing Address - Phone:864-225-7798
Mailing Address - Fax:864-260-3952
Practice Address - Street 1:500 N FANT ST
Practice Address - Street 2:SUITE C
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5702
Practice Address - Country:US
Practice Address - Phone:864-225-7798
Practice Address - Fax:864-260-3952
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT24202Medicaid
SCG24736Medicare UPIN
SC7033Medicare PIN