Healthcare Provider Details

I. General information

NPI: 1558363077
Provider Name (Legal Business Name): JAY R ERICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LINER DR
GREENWOOD SC
29646-2310
US

IV. Provider business mailing address

104 WELLS AVE
GREENWOOD SC
29646-3837
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-6371
  • Fax:
Mailing address:
  • Phone: 864-725-4673
  • Fax: 864-725-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number18669
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: