Healthcare Provider Details

I. General information

NPI: 1851422422
Provider Name (Legal Business Name): JESSE ANDREWE RALEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 FORT JACKSON BLVD STE 270
COLUMBIA SC
29209-1119
US

IV. Provider business mailing address

4500 FORT JACKSON BLVD STE 270
COLUMBIA SC
29209-1119
US

V. Phone/Fax

Practice location:
  • Phone: 803-764-3555
  • Fax: 803-764-4418
Mailing address:
  • Phone: 803-764-3555
  • Fax: 803-764-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number27936
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: