Healthcare Provider Details

I. General information

NPI: 1477544625
Provider Name (Legal Business Name): STACY BLYE GARMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N A ST
EASLEY SC
29640-2144
US

IV. Provider business mailing address

300 E MCBEE AVE
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-855-0001
  • Fax: 864-855-5030
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number160630
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier160630
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: