Healthcare Provider Details

I. General information

NPI: 1295794212
Provider Name (Legal Business Name): EDWARD JOSEPH JAKUBS II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 E HOSPITAL DR STE 400
WEST COLUMBIA SC
29169-4800
US

IV. Provider business mailing address

470 HULON LN
WEST COLUMBIA SC
29169-4841
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-3300
  • Fax: 803-936-7735
Mailing address:
  • Phone: 803-936-3300
  • Fax: 803-936-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number27836
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: