Healthcare Provider Details

I. General information

NPI: 1790988517
Provider Name (Legal Business Name): JENNIFER RACHELLE BERMICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER RACHELLE DALTON

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD-47653
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301090138
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301090138
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301090138
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-47653
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: