Healthcare Provider Details

I. General information

NPI: 1053383000
Provider Name (Legal Business Name): JONATHAN C COLLINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CENTRE SOUTH BLVD
AIKEN SC
29803-6319
US

IV. Provider business mailing address

30 CHERRY HILLS DR
AIKEN SC
29803-5691
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-9204
  • Fax: 803-648-3633
Mailing address:
  • Phone: 803-642-9525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number11083
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: