Provider Demographics
NPI:1205823754
Name:GILMORE, WADDELL H III (MD)
Entity Type:Individual
Prefix:DR
First Name:WADDELL
Middle Name:H
Last Name:GILMORE
Suffix:III
Gender:M
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:180 WINGO WAY STE 301
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1812
Practice Address - Country:US
Practice Address - Phone:843-884-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0683Medicaid
SCP00834851OtherRAILROAD MEDICARE ID-RSFPN
SC097825Medicaid
SC2216Medicare PIN
SCCA6815Medicare PIN
SC097825Medicaid
SCDM0683Medicaid
SCD055869223Medicare PIN
SCD055862216Medicare PIN