Basic Information
| Provider Information | |||||||||
| NPI: | 1679950570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | WYATT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 RICHLAND MEDICAL PARK DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034348450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 56409 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | 56409 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080P0206X | 86455 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.