Basic Information
| Provider Information | |||||||||
| NPI: | 1255371381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | CURTIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 INDEPENDENCE PT | ||||||||
| Address2: | STE 140 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | 8647976195 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 MAPLE TREE CT STE 103 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643151300 | ||||||||
| FaxNumber: | 8643151301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9313 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 093133 | 05 | SC | MEDICAID | 571004971025 | 01 | SC | BCBS OF SC | OTHER | 080170137 | 01 | SC | RR MEDICARE | OTHER |