MEDICARE: JACQUELINE DALLAIRE 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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	LL84080	SC

General Provider Information

NPI Number	:	1891218863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE DALLAIRE MD

Provider Business Mailing Address
First Line	:	169 ASHLEY AVENUE
Second Line	:	ROOM 202 MAIN HOSPITAL, MSC333
City	:	CHARLESTON
State	:	SC
Zip	:	29425
Country	:	US
Telephone Number	:	843-792-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	169 ASHLEY AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-1059
Country	:	US
Telephone Number	:	843-792-4500
Fax Number	:

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

Provider Enumeration Date	:	07/21/2017
Last Update Date	:	05/19/2020

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