Healthcare Provider Details

I. General information

NPI: 1952543035
Provider Name (Legal Business Name): JEREMIAH CHRISTIAN FOWLER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 ROBERTS ST
CAMDEN SC
29020-3737
US

IV. Provider business mailing address

148 WALL ST APARTMENT 432
CAMDEN SC
29020-7656
US

V. Phone/Fax

Practice location:
  • Phone: 803-432-4311
  • Fax:
Mailing address:
  • Phone: 843-457-1794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3878
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: