Basic Information
| Provider Information | |||||||||
| NPI: | 1063519064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILGORE | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOLLEY | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540888 | ||||||||
| FaxNumber: | 8644541130 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 LAUREL ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032275320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 279 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 28-00279 | 01 | SC | STATE DEA | OTHER | 576007863 | 01 | SC | AETNA | OTHER | 002794 | 05 | SC | MEDICAID | 57-6007863 | 01 | SC | BCBS | OTHER | BK1465459 | 01 | SC | FEDERAL DEA | OTHER | 57-6007863 | 01 | SC | BLUE CHOICE | OTHER | 110234017 | 01 | SC | MEDICARE RAILROAD | OTHER | 57-6007863 | 01 | SC | TRICARE | OTHER |