Healthcare Provider Details

I. General information

NPI: 1689655383
Provider Name (Legal Business Name): JEROME F MCCABE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 RIVERSIDE LANE
MURRELLS INLET SC
29576-6813
US

IV. Provider business mailing address

109 BEE ST
CHARLESTON SC
29401-5703
US

V. Phone/Fax

Practice location:
  • Phone: 843-421-5455
  • Fax:
Mailing address:
  • Phone: 843-577-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number21192
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7717100
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier2648513
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 3
Identifier211924
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 4
Identifier34195845111518
Identifier TypeOTHER
Identifier State
Identifier IssuerTRICARE WEST
# 5
Identifier1016473010001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 6
IdentifierP00267423
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerRXR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: