Healthcare Provider Details

I. General information

NPI: 1548274343
Provider Name (Legal Business Name): JEFFREY CLARK GERSBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 BURDEN CREEK RD
JOHNS ISLAND SC
29455-4604
US

IV. Provider business mailing address

2645 BURDEN CREEK RD
JOHNS ISLAND SC
29455-4604
US

V. Phone/Fax

Practice location:
  • Phone: 843-224-0880
  • Fax: 425-944-8954
Mailing address:
  • Phone: 843-559-1958
  • Fax: 843-225-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number021585
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14843
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101042360
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: