Basic Information
| Provider Information | |||||||||
| NPI: | 1992778377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 SAINT MATTHEWS RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291181442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036820344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 ST. MATTHEWS RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034542613 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 901 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 901 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009010 | 05 | SC | MEDICAID | 576008010002 | 01 | SC | TRICARE | OTHER | 576008010010 | 01 | SC | BCBS | OTHER | 7535722 | 01 | SC | AETNA | OTHER | 576008010007 | 01 | SC | BLUE CHOICE | OTHER | 6958751 | 01 | SC | CIGNA | OTHER |