Healthcare Provider Details

I. General information

NPI: 1619946415
Provider Name (Legal Business Name): BARRY H MADDOX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E GREENVILLE ST SUITE 3000
ANDERSON SC
29621-1580
US

IV. Provider business mailing address

2000 E GREENVILLE ST SUITE 3000
ANDERSON SC
29621-1580
US

V. Phone/Fax

Practice location:
  • Phone: 864-224-1055
  • Fax: 864-224-3773
Mailing address:
  • Phone: 864-224-1055
  • Fax: 864-224-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11543
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier545763886A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier115431
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: