Healthcare Provider Details

I. General information

NPI: 1487625240
Provider Name (Legal Business Name): JACK W SIMMONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2097 HENRY TECKLENBURG DR SUITE 312W
CHARLESTON SC
29414-5740
US

IV. Provider business mailing address

2097 HENRY TECKLENBURG DR SUITE 312W
CHARLESTON SC
29414-5740
US

V. Phone/Fax

Practice location:
  • Phone: 843-769-5620
  • Fax: 843-769-5625
Mailing address:
  • Phone: 843-769-5620
  • Fax: 843-769-5625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number10543
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: