Provider Demographics
NPI:1669654448
Name:DEGEN, JEROME B (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:B
Last Name:DEGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-536-9390
Mailing Address - Fax:803-533-0911
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 305
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-536-9390
Practice Address - Fax:803-533-0911
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC07054207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC070540Medicaid
SCC60992Medicare UPIN