Healthcare Provider Details

I. General information

NPI: 1982642880
Provider Name (Legal Business Name): GARY J BARRETT MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 CASEY ST
LORIS SC
29569
US

IV. Provider business mailing address

PO BOX 156
LORIS SC
29569
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-8090
  • Fax:
Mailing address:
  • Phone: 843-756-8090
  • Fax: 843-756-6122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11051
License Number StateSC

VIII. Authorized Official

Name: DR. GARY J BARRETT
Title or Position: OWNER
Credential: MD
Phone: 843-756-8090