MEDICARE: JEFFREY RUSSELL PIKE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	1385	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AA86079223	OTHER	SC	MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689825895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY RUSSELL PIKE PA

Provider Business Mailing Address
First Line	:	PO BOX 751649
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1649
Country	:	US
Telephone Number	:	843-789-1620
Fax Number	:	843-724-2440

Provider Business Practice Location Address
First Line	:	5070 INTERNATIONAL BLVD STE 131
Second Line	:
City	:	N CHARLESTON
State	:	SC
Zip	:	29418-6007
Country	:	US
Telephone Number	:	843-402-5053
Fax Number	:	843-724-1325

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	01/19/2022

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Directions to “ JEFFREY RUSSELL PIKE PA” Practice Location

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