Basic Information
| Provider Information | |||||||||
| NPI: | 1689012957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LITSEY | ||||||||
| FirstName: | JEDIDIAH | ||||||||
| MiddleName: | COLTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1595 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294835529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432128080 | ||||||||
| FaxNumber: | 4382128081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35722 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 357223 | 05 | SC | MEDICAID |