Provider Demographics
NPI:1083625321
Name:GAGNE-SABBAGH, CAMILLE G (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:G
Last Name:GAGNE-SABBAGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8024 MYRTLE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8945
Mailing Address - Country:US
Mailing Address - Phone:843-347-7333
Mailing Address - Fax:843-347-7288
Practice Address - Street 1:8024 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-347-7333
Practice Address - Fax:843-347-7288
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18924207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC790628OtherNORTH CAROLINA MEDICAID
SCT28725Medicaid
SCF856540281Medicare ID - Type Unspecified
SCT28725Medicaid