Provider Demographics
NPI:1558363077
Name:ERICKSON, JAY R (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:ERICKSON
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 1:104 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3837
Mailing Address - Country:US
Mailing Address - Phone:864-725-4673
Mailing Address - Fax:864-725-7424
Practice Address - Street 1:106 LINER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2310
Practice Address - Country:US
Practice Address - Phone:864-227-6371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18669207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT25381Medicaid
SCG20620Medicare UPIN