Healthcare Provider Details

I. General information

NPI: 1912007105
Provider Name (Legal Business Name): JARROD REYNOLDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1189 TIBWIN ROAD
MCCLELLANVILLE SC
29458-9405
US

IV. Provider business mailing address

P.O. BOX 608
MCCLELLANVILLE SC
29458-0608
US

V. Phone/Fax

Practice location:
  • Phone: 843-887-3274
  • Fax: 843-887-3929
Mailing address:
  • Phone: 843-887-3274
  • Fax: 843-887-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number82614
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27091
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: