Basic Information
| Provider Information | |||||||||
| NPI: | 1801859640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTTER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 BAYLOR DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437058919 | ||||||||
| FaxNumber: | 8437057024 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 BAYLOR DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437058919 | ||||||||
| FaxNumber: | 8437057024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 200300326 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | TL31669 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 89134Y8 | 05 | NC | MEDICAID | 316697 | 05 | SC | MEDICAID |