Provider Demographics
NPI:1043504020
Name:RILEY, JENNY MCCALLISTER (MD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MCCALLISTER
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9313 MEDICAL PLAZA DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9802
Mailing Address - Country:US
Mailing Address - Phone:843-790-8280
Mailing Address - Fax:843-974-8500
Practice Address - Street 1:9313 MEDICAL PLAZA DR STE 103
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9802
Practice Address - Country:US
Practice Address - Phone:843-790-8280
Practice Address - Fax:843-974-8500
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33673207RH0003X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC336737Medicaid