=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225319130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY G KIRKHAM JR. D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2011
-----------------------------------------------------
Last Update Date | 12/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 RICHLAND MEDICAL PARK DR STE 320
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-6896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-434-6771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 MEDICAL CENTER DR STE 205
-----------------------------------------------------
City | SEWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08080-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-542-2273
-----------------------------------------------------
Fax | 856-553-4390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 25MB09418500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 83693
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 25MB09418500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 83693
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | H90000
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------