Healthcare Provider Details

I. General information

NPI: 1730685025
Provider Name (Legal Business Name): JIE YU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 BLACK RIVER RD
GEORGETOWN SC
29440
US

IV. Provider business mailing address

606 BLACK RIVER RD
GEORGETOWN SC
29440
US

V. Phone/Fax

Practice location:
  • Phone: 843-520-8405
  • Fax: 843-520-8459
Mailing address:
  • Phone: 843-520-8405
  • Fax: 843-520-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number86613
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: