Healthcare Provider Details

I. General information

NPI: 1093719320
Provider Name (Legal Business Name): JOHN B EBERLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 OLD SPARTANBURG RD
TAYLORS SC
29687-4105
US

IV. Provider business mailing address

4501 OLD SPARTANBURG RD
TAYLORS SC
29687-4105
US

V. Phone/Fax

Practice location:
  • Phone: 864-268-1119
  • Fax: 864-268-1714
Mailing address:
  • Phone: 864-268-1119
  • Fax: 864-268-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14967
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: