Healthcare Provider Details

I. General information

NPI: 1003815358
Provider Name (Legal Business Name): MICHAEL JAY WHITE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 PONDFIELD RD SUITE A
NEWBERRY SC
29108-9522
US

IV. Provider business mailing address

PO BOX 749306
ATLANTA GA
30374-9306
US

V. Phone/Fax

Practice location:
  • Phone: 803-405-7230
  • Fax:
Mailing address:
  • Phone: 803-796-4251
  • Fax: 803-796-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number73670
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME108837
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23345
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number073670
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: