Basic Information
| Provider Information | |||||||||
| NPI: | 1902906712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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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: | 200 N NELSON DRIVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN INN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645226270 | ||||||||
| FaxNumber: | 8645226275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | 28058 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207R00000X | 28058 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 280582 | 05 | SC | MEDICAID | P00801532 | 01 | SC | RR MEDICARE | OTHER |