MEDICARE: JACK LEGRAND DEPRIEST MD

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	MD065996L	PA
2	208M00000X	Hospitalist Physician	23454	WV
3	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	81661	SC

Other Identifiers

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

General Provider Information

NPI Number	:	1881699957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK LEGRAND DEPRIEST MD

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE FL 4
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2842
Country	:	US
Telephone Number	:	864-522-8603
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 RICHLAND MEDICAL PARK DR STE 300
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6831
Country	:	US
Telephone Number	:	803-545-5500
Fax Number	:

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/23/2024

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Directions to “ JACK LEGRAND DEPRIEST MD” Practice Location

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