Healthcare Provider Details

I. General information

NPI: 1245244342
Provider Name (Legal Business Name): JOHN O. FAIREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 TAYLOR ST SUITE 1A
COLUMBIA SC
29201-2942
US

IV. Provider business mailing address

1301 TAYLOR ST SUITE 1A
COLUMBIA SC
29201-2942
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-4591
  • Fax: 803-931-8000
Mailing address:
  • Phone: 803-254-4591
  • Fax: 803-931-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number11357
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: