Provider Demographics
NPI:1134129174
Name:FURNESS, GREGORY (PAC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:FURNESS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6925 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-3801
Mailing Address - Country:US
Mailing Address - Phone:803-518-0137
Mailing Address - Fax:
Practice Address - Street 1:6925 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3801
Practice Address - Country:US
Practice Address - Phone:803-518-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2046207RC0000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0289PAMedicaid
SC0289PAMedicaid
SCAA03672121Medicare ID - Type Unspecified