Provider Demographics
NPI:1447266325
Name:EGBERT, JOHN RAYMOND (MD PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAYMOND
Last Name:EGBERT
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 RICHLAND MEDICAL PARK
Mailing Address - Street 2:STE 203 PALMETTO SENIOR CARE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-3770
Mailing Address - Fax:803-434-3773
Practice Address - Street 1:15 RICHLAND MEDICAL PARK
Practice Address - Street 2:STE 203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-3770
Practice Address - Fax:803-434-3773
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11087207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D99382Medicare UPIN