Healthcare Provider Details

I. General information

NPI: 1225193105
Provider Name (Legal Business Name): JEAN-RONEL CORBIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORP PKWY SUITE 106
INDIAN LAND SC
29707-4514
US

IV. Provider business mailing address

1040 EDGEWATER CORP PKWY SUITE 106
INDIAN LAND SC
29707-4514
US

V. Phone/Fax

Practice location:
  • Phone: 704-541-9117
  • Fax: 704-541-9137
Mailing address:
  • Phone: 704-541-9117
  • Fax: 704-541-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number2006-01910
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number200601910
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: