MEDICARE: DR. TEMISAN L ETIKERENTSE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	20234	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	JB021564	OTHER	SC	JUA
2	571134452	OTHER		FEDERAL IN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	20 20234	OTHER	SC	STATE REGISTRATION
5	20234	OTHER	SC	MEDICAL LICENSE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	562413454	OTHER	SC	SECONDARY TAX ID
8	562413454	OTHER		FEDERAL IN
9	75767	OTHER	SC	SC PCF
10	9800859	OTHER	NC	MEDICAL LICENSE
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	JB021584	OTHER		JUA

General Provider Information

NPI Number	:	1710986757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TEMISAN L ETIKERENTSE MD

Provider Business Mailing Address
First Line	:	783 NAVIGATORS RUN
Second Line	:
City	:	MT. PLEASANT
State	:	SC
Zip	:	29464-2829
Country	:	US
Telephone Number	:	843-886-6729
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-899-9099
Fax Number	:	843-899-9091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	03/07/2023

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