Individual
JEROME H WALLER JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
300 W FRONT ST, LIBERTY, SC 29657-1012
(864) 843-5605
(864) 843-0996
Mailing address
300 E MCBEE AVE FL 4, GREENVILLE, SC 29601-2842
(864) 522-8603
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
016611
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
166117
—
SC
Enumeration date
05/17/2006
Last updated
06/30/2021
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