Healthcare Provider Details

I. General information

NPI: 1235176520
Provider Name (Legal Business Name): JOHN P SHORT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4780
  • Fax: 864-725-4778
Mailing address:
  • Phone: 864-725-4780
  • Fax: 864-725-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1982
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2001
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1651
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: