Basic Information
| Provider Information | |||||||||
| NPI: | 1881699957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEPRIEST | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LEGRAND | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967303 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 RICHLAND MEDICAL PARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 23454 | WV | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | 81661 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | MD065996L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001699305 | 05 | PA | MEDICAID | 816610 | 05 | SC | MEDICAID |